08/2-7, 2012

SEM 1 Year 2 IV.

COURSE III: PULMONOLOGY

[Cough] Chronic Obstructive Pulmonary Disease

CLINICAL FEATURES (from history & PE)

COPD: cough, sputum production, and exertional dyspnea. History: heaviness, air hunger, or gasping - principal feature is worsening dyspnea on exertion - arm work activities, particularly at or above

shoulder level are difficult - advanced stages- patients are breathless doing ADL. PE: odor of smoke or nicotine staining of fingernails - expiratory wheezing - Barrel Chest (Hyperinflation) - Use of Accessory muscle, weight loss, ankle swelling (Cor pulmonale) - Sitting in Tripod postion (facilitate the actions of the SCM, scalene, and ICS)
- Cyanosis:

"pink puffers" - thin and noncyanotic at rest ,use of accessory muscles "blue bloaters"- patients with chronic bronchitis are more likely to be heavy and cyanotic
V. DIAGNOSIS

Pulmonary function testing a. Spirometry- Short acting Beta 2 agonist/ anti cholinergic (measure after 10-15 for b2 agonist, 30-45 for anti-Cholinergic) FEV1 -airflow obstruction with a reduction in FEV1 and FEV1/FVC (<.70) increase in total lung capacity, functional residual capacity, and residual volume (Increased Lung Volume)

DREAMERS ADZU-SOM II

COMPILED BY: (CHRISTIAN YECYECAN)

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08/2-7, 2012

SEM 1 Year 2

COURSE III: PULMONOLOGY

[Cough] Chronic Obstructive Pulmonary Disease

b. Arterial blood gases and oximetry -resting or exertional hypoxemia. - alveolar ventilation and acid-base status by measuring arterial PCO2 and pH.
- change in pH with PCO2 is 0.08 units/10 mmHg

acutely and 0.03 units/10 mmHg in the chronic state c. CBC- elevated hematocrit suggests the presence of chronic hypoxemia, as does the presence of signs of right ventricular hypertrophy d. CXR- Obvious bullae, paucity of parenchymal markings, or hyperlucency suggests the presence of emphysema e. CT- definitive test presence or absence of emphysema f. Serum Alpha1 Antitrypsin testing- Dec 15-20 %
of normal

g. Exercise Testing- 6 minute unpaced walk test h. ECG and 2Decho- Right ventricular hypertrophy Cor Pulmonale- tall P wave RV Hypertrophy- tall R wave, Persistent S
wave from V1-V6 VI. TREATMENT Goals- Reduce Symptoms Reduce Risk A.Smoking Cessation Nicotine replacement(gum,Inhaler, lozenge) except for those w/ CAD, Untreated PUD, recent MI or CVD. - Tx: Varenicline , bupropion, notriptyline - 5 step program: ASK, ADVISE, ASSESS, ASSIST,ARRANGE B.Pharmacologic: I. Bronchodilators Beta 2 Agonist- relax smooth muscle, stimulating beta2 adrenergic receptors, increases cyclic AMP> antagonism to bronchoconstriction Adverse effect: Tachycardia a. Short Acting- Fenoterol 100-200 mcg, Salbutamol 100 or 200 mcg, Terbutaline 400,500 mcg (4-6 hours duration) b. Long Acting-Formoterol 4.5-

DREAMERS ADZU-SOM II

COMPILED BY: (CHRISTIAN YECYECAN)

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08/2-7, 2012

SEM 1 Year 2

COURSE III: PULMONOLOGY

[Cough] Chronic Obstructive Pulmonary Disease

12 mcg. Salmeterol 25-50 mcg(12 hours) II. AntiCholinergics- blocks acetylcholines effect on muscarinic receptors and modifies transmission at the pre ganglionic junction Adverse effects: Dryness of Mouth, Less/ Very Safe a. Short Acting(M2 and M3)Ipratropium Bromide20-40 mcg (6-8 Hours) b. Long Acting( M3 and M1)Tiotropium 18 mcg( 24 hours) III. Methylxanthines- Act as non selective phosphodiesterase inhibitors Adverse Effects: Atrial and Ventricular Arrythmia, Convulsions Theophylline -200-600 mg,oral(24 hours) A IV. Inhaled Corticosteroids Adverse Effects-risk for reduced bone density, hoarse voice, skin bruising, oral candidiasis, risk for pneumonia Beclamethasone 50-400 mcg Budesonide 100,200,400 mcg Fluticasone 50-500 mcg

o2 sat <88 or <90%, with Rt. Heart Failure c. Lung Volume Reduction SurgeryImproves mechanical efficacy of resp muscles. Increases elastic recoil pressure and improves Exp. Flow rates. d. Bullectomy- for bolus emphysema e. Mech VentNIPPV-for patients w/ resp failure (PaCO2.45mmhg), except for CV instability, inability to clear secretions,trauma, extreme obesity, burns Invasive- for reps. Arrest, impaired mental Status, resp. distress despite therapy, Hypercarbia, life threatening hypoxemia 1 Choice SA Anticholinergi c Or SABA (PRN) B LACA or LABA
st

nd

CHoice

Alternative Theophyilline

LACA or LABA Or SABA + SA anti Cholinergic LABA + LACA

SABA and/ or SA anticholinergic + Theophylline PDE 4 inhibitor + SABA and/or SA anticholinergic + Theophylline

V. Phosphodiesterase Inhibitors- inhibits breakdown of intracellular cyclic AMP Adverse effects: nausea, reduced appetite, abd. Pain, diarrhea, sleep distrubances, headache Roflumilast, 500mcg, oral (24 hours) Vaccines- killed or live a. Influenza b. Pneumococcal- 65 and older VII. Alpha1 AT Augmentation Therapy VIII. Antibiotics IX. Mucolytics and Antioxidants X. Antittusives C.Non Pharmacologic a. Pulmonary Rehabilitation I. Exercise Training- 6 minute walking, daily 10-45 minutes II. Education and Nutrition b. Oxygen Therapy- if w/ resting hypoxemia/ DREAMERS ADZU-SOM II VI.

Inhaled ICS + LABA or LACA

LACA + LABA

Inhaled ICS + LABA or LA anticholinergi c

-Inhaled ICS + LABA/ or Inhaled ICS w/ LABA and LACA Or Inhaled ICS w/ LABA & PDE4 Or LABA + LACA Or LACA+ PDE4

Carbocysteine + SABA and/ or SACA + Theophylline

COMPILED BY: (CHRISTIAN YECYECAN)

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