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Treatment ofCOPD

TREATMENT OF COPD

•Stop smoking - prevents further damage•Short acting bronchodilator

- β2-agonist (e.g.. inhaled salbutamol)- anticholinergic (e.g.. inhaled ipratropium)

•Long acting bronchodilator- β2-agonist (e.g.. inhaled salmeterol)- anticholinergic (e.g.. inhaled tiotropium)

•Inhaled corticosteroids if FEV < 50 % predicted and frequent exacerbations. •Oxygen therapy if hypoxic•Theophyllines•Vaccination against influenza and pneumococcus•Optimize weight•Pulmonary rehabilitation•Palliative care – opiates, benzodiazepines

COPD EXACERBATIONS

•History – increased shortness of breath with cough productive of more purulent sputum.•Examination – Assess severity - Respiratory rate, cyanosis, tachycardia, blood pressure, breath sounds and oedema.•Investigations – CXR, ABGs, FBC, U+E, ECG, sputum culture if purulent.•Treatment – nebulized bronchodilators, controlled oxygen – aim for O2 sat > 90 % (balance hypoxia against hypercarbia and acidosis), antibiotics if evidence of infection, systemic steroids, •Consider non-invasive ventilation.•Early assisted discharge

•Consider non infective causes of exacerbations e.g. pulmonary emboli, heart failure or pneumothorax.

Facial Burns - Smoking while on Oxygen!!

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Problem Solving – COPD 1

HISTORY:

A 70 year old man with a long standing history of COPD and smokes 40 cigarettes/day calls 999 with worsening breathless and over the past few days. He arrives in hospital by ambulance.

On examination he is drowsy and confused, respiratory rate is 10/min and there is a flapping tremor. He has markedly diminished breath sounds with wheezing. Arterial blood gases show: PaO2 11.5 kPa, SaO2 95%, PaCO2 9.2 KPa, pH 7.27, HCO3 37mmol/l (normal PaO2 > 12KPa, SaO2 > 98%, PaCO2 < 5KPa, pH 7.35 - 7.40, HCO3 25-30mmol/l.Chest X-ray shows emphysematous lung fields with no consolidation.

A. Describe the pattern of blood gases abnormality.

B. What is the likely oxygen concentration that he is being given?

C. Describe the pathophysiological process which resulted in the pattern of blood gases abnormality.

D. What modification of his treatment is needed?

E. What is the most important advice to give regarding his lifestyle on discharge?

Problem Solving – COPD 2

HISTORY:

A 65 year old smoker (40/day) is admitted to the accident and emergency department with a recent onset of increasing breathlessness. He had a cold and now has a cough productive of green phlegm.

His lips are cyanosed, his respiratory rate is 20/minute and he has reduced breath sounds with wheezing but no crackles. A chest X-ray shows no evidence of consolidation or pneumothorax. Arterial blood gases (breathing air show: PaO2 5.7 kPa, PaCO2 6.8kPa, pH 7.35 O2 sat 86% (normal: Pa O2 > 12, PaCO2 < 5, pH 7.35).

A. Describe the abnormality of his blood gases.

B. What has tipped him into decompensation?

C. What is the initial management?

D. He has not improved 1 hour after initial drug therapy and his repeat blood gasses are: PaO2 5.8KPa, PaC 8.2KPa, pH 7.23. What form of ventilatory support should be considered?

E. Despite all treatment he has continued to deteriorate and is now tiring. What factors will determine whether he should be referred to ITU?

PathogenesisOf Asthma

Laminates beside board

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SymptomologyOf Asthma

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DIAGNOSIS OF ASTHMA

History and examination

Diurnal variation of peak flow rate > 20%

Spirometry may be normal

Reversibility to inhaled salbutamol (FEV1 > 15%)

Provocation testing hyperrsponsiveness

- exercise - histamine inhalation

Diagnosis of Asthma

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ACUTE ASTHMA - PROBLEM SOLVING

HISTORY:

A 20 year old man is admitted to the accident and emergency department with an onset of worsening breathlessnessand wheeze following a recent cold. He has a history of mild episodic asthma and normally only requires his salbutamol inhaler prior to exercise.On presentation he has difficulty completing his sentences and is feeling increasingly exhausted with the effort of breathing.His pulse rate is 125/min, respiratory rate 40/min, PEFR 100 l/min. He has reduced breath sounds and widespread wheezing. Arterial blood gases (breathing air) show:

PaO2 7.0KPa, PaCO2 4.1KPa, pH 7.41 (normal: PaO2 > 12, PaCO2 < 5, pH 7.35).

A. Describe the pattern of his blood gas derangement. What happens to PaCO2 with increasingly severe acute asthma?

B. What immediate drug therapy would you give?

• Which of the two O2 masks is most appropriate (24% or 60%)?

• What clinical observations might suggest he is responding to clinical treatment?

• If he does not respond to initial treatment what other test should you think of doing?

F.Repeat blood gases after 1 hour show (on 60% O2) PaO2 5.5K-Pa (from 7.0) PaCO2 7.2KPa (from 4.1) pH 7.20 (from 7.41). Respiratory rate is now 20/minute (from 40/minute), and he is unable to speak or record a peak flow. What is happening and what management do you need to instigate as soon as possible?

Resp Wk2 09ATREATMENT OF

ASTHMA

Non-pharamacological treatment

Stop smokingAllergen avoidanceBreastfeedingBreathing exercises Weight reduction if obese

Maintenance Treatment of Asthma

A. Anti-inflammatory (Preventers)•Corticosteroid (e.g. beclomethasone) - given by inhaled route (low doses)high local effect in airway minimal systemic side-effects •Cromoglycate- mast cell stabiliser

B. Bronchodilators (Relievers)• 2-agonistse.g. salbutamol - used for acute relief of bronchospasm sameterol - used for long duration (e.g. at night) - given by inhaled route

C. Leukotriene receptor antagonist

A3 made from pdf

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Effects of three months inhaled corticosteroids

Asthmatic Steroid-treated Asthmatic

Inhaler devices