COPD - Chronic Obstructive Pulmonary Disease Kai Stürmann,...

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Unformatted text preview: 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 crazy­ass 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 born­again 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 ...
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This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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