copd_ae - Chronic Obstructive Airway Disease-Acute...

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1 Chronic Obstructive Airway Disease-Acute Exacerbation Dr. Zia Hashim September 17, 2004 Definition ± Sustained worsening of pt’s symptoms ± From usual stable state ± Beyond normal day to day variation ± Acute onset ± Often necessitates a change in medication Anthonisen et al ± Based on three cardinal symptoms worsening of dyspnea, sputum purulence, sputum volume Type 1(severe): all 3 Type 2(moderate): 2 of these Type 3(mild): 1 of these + 1of following Unexplined fever, URTI in past 5 days, wheeze, cough, RR/HR 20% above baseline Consequences ± A retrospective audit of 1400 pts in UK has shown 34% were readmitted 14% had died within 3 month of an exacerbation ± Median time of recovery symptoms: 7 d PEFR: 6 d ± Incomplete recovery of lung function following an exacerbation recovery of PEFR not complete 25% at 35 d 7% at 90 d
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2 Patients experiencing frequent exacerbations (>2.92/yr) have more rapid decline in lung function (FEV1 fall 40 ml/yr vs 32 ml/yr). ed level of IL-6 & IL-8 is found in patients with frequent exacerbations Factors associated with risk of readmission ± 3 admissions in the previous yr ± FEV 1 % predicted ± PaO 2 ± Lower level of physical activity ± Need for an anticholinergic brochodilator Mechanism of Exacerbation ± Increased breahlessness Airway narrowing mucosal damage, increased irritability/ bronchospasm inflammatory cell infiltration into airway tissues airway edema increased airway secretion and viscosity/ mucus plugging V/Q mismatch Increased metabolic/catabolic rate ± Increased sputum production mucosal gland hypertrophy goblet cell hyperplasia goblet cell degranulation ± New or increased sputum purulence eosinophil recruitment neutrophil recruitment
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3 Causes ± Infections : Viral Rhinoviruses Influenza Parainfluenza Coronavirus Adenovirus RSV Bacterial C pneumoniae H influenzae S pneumoniae M catarrhalis Staph aureus P aeruginosa Non infective causes ± Nitrogen dioxide ± Particulates ± Sulphur dioxide ± Ozone ± Unidentified causes in 30% Mimickers ± Pneumonia ± Pneumothrax ± LVF/pulmonary edema ± Pulmonary embolus ( 30%) ± Lung cancer ± Upper airway obstruction ± Pleural effusion ± Recurrent aspiration
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4 Hospital or Home? Patients with following features should be admitted ± Cyanosis ± Worsening pedal edema ± Impaired level of consciousness ± Already receiving LTOT ± pH<7.35 ± PaO 2 <49 ± CXR changes Investigations ± ABG ± ECG ± CXR ± Haemogram ± SERFT ± Sputum c/s: limited value ± Theophylline level ± Blood c/s: if fever ± Lung function: not practical PEF< 100, FEV1< 1 indicates severe exacerbation Systemic Coticosteroids 3 systematic reviews: McCory et al, Wood-Baker et al, Singh et al ± Significant effect in favor of steroids over placebo in terms of FEV1 for at least 72 h ± Improvement in oxygenation ± Shorter duration of hospitalization
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This note was uploaded on 12/03/2011 for the course MEDICINE 350 taught by Professor Dr.aslam during the Winter '07 term at Medical College.

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copd_ae - Chronic Obstructive Airway Disease-Acute...

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