Chronic Obstructive Pulmonary Disease: Kai Stürmann, Md Associate Professor, Clinical Emergency Medicine Aecom
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Chronic Obstructive Pulmonary Disease: Kai Stürmann, Md Associate Professor, Clinical Emergency Medicine Aecom as PDF for free.
More details
- Words: 947
- Pages: 48
Chronic Obstructive Pulmonary Disease Kai Stürmann, MD Associate Professor, Clinical Emergency Medicine AECOM
Where’s the church, who took the steeple? Religion is in the hands of some crazy-ass people Television preachers with bad hair and dimples The God’s honest truth is it’s not that simple It’s the Buddhist in you, it’s the pagan in me… It’s the Muslim in him, she’s Catholic ain’t she? It’s the born-again look, it’s the Wasp and the Jew Tell me what’s goin on, I ain’t gotta clue… - Jimmy Buffett
COPD - Guidelines American Thoracic Society European Respiratory Society British Thoracic Society GOLD – WHO – NIH
COPD - Guidelines American College of Physicians / ACCP Agency for Healthcare Research and
Quality – www.ahcpr.gov/clinic/epcsums/copdsum.htm
Definitions Emphysema - abnormal permanent enlargement of the airspace distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
Chronic Bronchitis - presence of chronic productive cough for 3 months in each of 2 successive years…
COPD - disease state characterized by airflow limitation that is not fully reversible.
COPD Will you know it when you see it? A 52-year-old smoker with recurrent respiratory infections and wheeze…
COPD Will you know it when you see it? the 52-year-old smoker with, and without, a history of chronic bronchitis.
COPD Will you know it when you see it? the 52-year-old male the 52-year-old female
COPD - Epidemiology
9.34 / 1000 (males) 7.33 / 1000 (females) ~14,000,000 Americans 700,000 hospital D/Cs per year female > male since 1992
COPD - Etiology Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm
Etiology 15% of smokers develop COPD 10% of COPD patients did not smoke alpha-1 antitrypsin deficiency occupational dusts and chemicals passive smoking (SAPALDIA study)
COPD - Pathophysiology Chronic airflow obstruction of small
airways enzymatic destruction of lung parenchyma loss of lung elasticity macrophages, neutrophils CD8+ T-lymphocytes (COPD) CD4+ T-lymphocytes (asthma)
Pathophysiology Tobacco smoke ⇒ loss of surfactant ⇑ goblet cells cellular activation macrophages / neutrophils neutrophil elastase cathepsins matrix metalloproteinases
Differential Diagnosis Asthma CHF / ACS pulmonary embolism pneumonia pneumothorax
Asthma and COPD
If there is clinical evidence of wheezing treat as if a reversible condition.
Congestive Heart Failure Orthopnea / dyspnea on exertion HJR Chest x-ray PEFR β -natruretic peptide
COPD v. PE
Consider risk factors pleuritic chest pain arterial blood gas
COPD - Differential Diagnosis
Acute Coronary Syndrome Pneumothorax Pneumonia Lobar Atelectasis
COPD Evaluation - History Acuity of onset chest pain change in sputum production fever hemoptysis orthopnea
COPD history - baseline status Last ED visit last hospital admission prior intubations home oxygen How bad is this attack?? PMH
COPD Medication History Inhalers steroids oxygen theophylline non-compliance drug-drug interactions
COPD - ED examination General / airway breathing – – – –
general trachea neck veins chest wall movement / auscultation
circulation
COPD - patient monitoring
EKG O2 saturation capnometry IV access
COPD - diagnostic studies
Arterial blood gases CBC / SMA6 aminophylline level brain natruretic peptide
COPD - diagnostic studies
spirometry sputum analysis CXR EKG
COPD treatment - O2
If oxygen saturation < 90-92% – maintain PaO2 > 60 mmHg – maintain SaO2 > 90%
nasal cannula v. venturi mask ↓ FiO2 as condition improves
β agonists / anticholinergics
both effective combination therapy more effective MDI v. nebulizer compressed air v. oxygen
COPD - corticosteroids
oral intravenous inhaled
Methylxanthines
No significant ↑ in FeV1 No significant ↓ in hospital admissions ↑ adverse effects check theophylline level if indicated
COPD - Antibiotics
increased dyspnea increased sputum production increased sputum volume
- Anthonisen NR, et al.
Ann Intern Med 1987
Non-invasive assisted ventilation ↑ tidal volume Prevents collapse of distal airways ↓ work of respiration Improves ABG’s, pH ↓ need for intubation ↓ length of stay COPD v. asthma
NIV - Indications inability to maintain O2 saturation >90% moderate acidosis (pH 7.30 – 7.35) RR > 25 / minute patient must be – alert – breathing – able to cooperate
NIV - Contraindications apnea pneumothorax inability to protect airway altered mental status C-V instability increased secretions
NIV – CPAP and BiPAP Pressure controlled devices Continuous positive airway pressure – 5 cm H2O
Bi-level positive airway pressure – 8-10 cm H2O / 2-4 cm H2O
Non-invasive ventilation…
Advantages – No need for ICU – Reduced mortality – Lower incidence of pneumonia – Cost effective
Non-invasive ventilation… Disadvantages – Discomfort / claustrophobia – Poor fit – leaks / facial trauma – Gastric distension
***Remember to ensure close observation for your patient***
COPD–Endotracheal intubation RR > 35 / min PaO2 < 40mmHg pH < 7.25 / PaCO2 > 60 mmHg Altered mental status C-V instability NIV failure Cardiac arrest (!)
ETT / RSI considerations Re-evaluate paralysis Etomidate Ketamine Succinylcholine v. rocuronium ETT size
Ventilator considerations short inspiratory time prolonged expiratory time decreased minute ventilation PEEP keep pCO2 elevated pneumothorax v. dynamic hyperinflation
Interventions / New horizons Interventions – Smoking cessation – Influenza vaccine
On the horizon… – Lung volume reduction surgery – tiotropium
Smoking Cessation death / illness reduction even if late before success → 5–7 attempts on average 5-10% success rate without assistance average weight gain of 4-6 kilos anxiety, insomnia, depressed mood
Smoking Cessation brief advice v. no advice Nicotine replacement therapy v. placebo Bupropion v. placebo physical exercise Professional advice Acupuncture v. sham treatment anxiolytics
Smoking Cessation brief advice 12% v. no advice 10% nicotine replacmt 17% v. placebo 10% Bupropion v. placebo physical exercise Professional advice 10% v. 10% Acupuncture v. sham treatment anxiolytics
Where’s the church, who took the steeple? Religion is in the hands of some crazy-ass people Television preachers with bad hair and dimples The God’s honest truth is it’s not that simple It’s the Buddhist in you, it’s the pagan in me… It’s the Muslim in him, she’s Catholic ain’t she? It’s the born-again look, it’s the Wasp and the Jew Tell me what’s goin on, I ain’t gotta clue… - Jimmy Buffett
COPD - Guidelines American Thoracic Society European Respiratory Society British Thoracic Society GOLD – WHO – NIH
COPD - Guidelines American College of Physicians / ACCP Agency for Healthcare Research and
Quality – www.ahcpr.gov/clinic/epcsums/copdsum.htm
Definitions Emphysema - abnormal permanent enlargement of the airspace distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
Chronic Bronchitis - presence of chronic productive cough for 3 months in each of 2 successive years…
COPD - disease state characterized by airflow limitation that is not fully reversible.
COPD Will you know it when you see it? A 52-year-old smoker with recurrent respiratory infections and wheeze…
COPD Will you know it when you see it? the 52-year-old smoker with, and without, a history of chronic bronchitis.
COPD Will you know it when you see it? the 52-year-old male the 52-year-old female
COPD - Epidemiology
9.34 / 1000 (males) 7.33 / 1000 (females) ~14,000,000 Americans 700,000 hospital D/Cs per year female > male since 1992
COPD - Etiology Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm Tobacco smoke, tobacco smoke, tobacco sm
Etiology 15% of smokers develop COPD 10% of COPD patients did not smoke alpha-1 antitrypsin deficiency occupational dusts and chemicals passive smoking (SAPALDIA study)
COPD - Pathophysiology Chronic airflow obstruction of small
airways enzymatic destruction of lung parenchyma loss of lung elasticity macrophages, neutrophils CD8+ T-lymphocytes (COPD) CD4+ T-lymphocytes (asthma)
Pathophysiology Tobacco smoke ⇒ loss of surfactant ⇑ goblet cells cellular activation macrophages / neutrophils neutrophil elastase cathepsins matrix metalloproteinases
Differential Diagnosis Asthma CHF / ACS pulmonary embolism pneumonia pneumothorax
Asthma and COPD
If there is clinical evidence of wheezing treat as if a reversible condition.
Congestive Heart Failure Orthopnea / dyspnea on exertion HJR Chest x-ray PEFR β -natruretic peptide
COPD v. PE
Consider risk factors pleuritic chest pain arterial blood gas
COPD - Differential Diagnosis
Acute Coronary Syndrome Pneumothorax Pneumonia Lobar Atelectasis
COPD Evaluation - History Acuity of onset chest pain change in sputum production fever hemoptysis orthopnea
COPD history - baseline status Last ED visit last hospital admission prior intubations home oxygen How bad is this attack?? PMH
COPD Medication History Inhalers steroids oxygen theophylline non-compliance drug-drug interactions
COPD - ED examination General / airway breathing – – – –
general trachea neck veins chest wall movement / auscultation
circulation
COPD - patient monitoring
EKG O2 saturation capnometry IV access
COPD - diagnostic studies
Arterial blood gases CBC / SMA6 aminophylline level brain natruretic peptide
COPD - diagnostic studies
spirometry sputum analysis CXR EKG
COPD treatment - O2
If oxygen saturation < 90-92% – maintain PaO2 > 60 mmHg – maintain SaO2 > 90%
nasal cannula v. venturi mask ↓ FiO2 as condition improves
β agonists / anticholinergics
both effective combination therapy more effective MDI v. nebulizer compressed air v. oxygen
COPD - corticosteroids
oral intravenous inhaled
Methylxanthines
No significant ↑ in FeV1 No significant ↓ in hospital admissions ↑ adverse effects check theophylline level if indicated
COPD - Antibiotics
increased dyspnea increased sputum production increased sputum volume
- Anthonisen NR, et al.
Ann Intern Med 1987
Non-invasive assisted ventilation ↑ tidal volume Prevents collapse of distal airways ↓ work of respiration Improves ABG’s, pH ↓ need for intubation ↓ length of stay COPD v. asthma
NIV - Indications inability to maintain O2 saturation >90% moderate acidosis (pH 7.30 – 7.35) RR > 25 / minute patient must be – alert – breathing – able to cooperate
NIV - Contraindications apnea pneumothorax inability to protect airway altered mental status C-V instability increased secretions
NIV – CPAP and BiPAP Pressure controlled devices Continuous positive airway pressure – 5 cm H2O
Bi-level positive airway pressure – 8-10 cm H2O / 2-4 cm H2O
Non-invasive ventilation…
Advantages – No need for ICU – Reduced mortality – Lower incidence of pneumonia – Cost effective
Non-invasive ventilation… Disadvantages – Discomfort / claustrophobia – Poor fit – leaks / facial trauma – Gastric distension
***Remember to ensure close observation for your patient***
COPD–Endotracheal intubation RR > 35 / min PaO2 < 40mmHg pH < 7.25 / PaCO2 > 60 mmHg Altered mental status C-V instability NIV failure Cardiac arrest (!)
ETT / RSI considerations Re-evaluate paralysis Etomidate Ketamine Succinylcholine v. rocuronium ETT size
Ventilator considerations short inspiratory time prolonged expiratory time decreased minute ventilation PEEP keep pCO2 elevated pneumothorax v. dynamic hyperinflation
Interventions / New horizons Interventions – Smoking cessation – Influenza vaccine
On the horizon… – Lung volume reduction surgery – tiotropium
Smoking Cessation death / illness reduction even if late before success → 5–7 attempts on average 5-10% success rate without assistance average weight gain of 4-6 kilos anxiety, insomnia, depressed mood
Smoking Cessation brief advice v. no advice Nicotine replacement therapy v. placebo Bupropion v. placebo physical exercise Professional advice Acupuncture v. sham treatment anxiolytics
Smoking Cessation brief advice 12% v. no advice 10% nicotine replacmt 17% v. placebo 10% Bupropion v. placebo physical exercise Professional advice 10% v. 10% Acupuncture v. sham treatment anxiolytics
Related Documents
Chronic Obstructive Pulmonary Disease
October 2019 26
Chronic Obstructive Pulmonary Disease
May 2020 20
Chronic Obstructive Pulmonary Disease ( Copd)
July 2020 12
Chronic Obstructive Pulmonary Disease Evaluation
October 2019 31
Chronic Obstructive Pulmonary Disease (copd)
June 2020 9
Disease Management For Chronic Obstructive Pulmonary Disease
November 2019 44More Documents from "National Pharmaceutical Council"
