1. Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in idividual patients.

2. Its pulmonary component is charachterized by airflow limitation that is not fully reversible. The airflow limitation is ususally progressive and asssociated with an abnormal inflammatory response of the lung to noxious particles or gases

-fourth leading cause of death

-rising in women

-Second leading cause of disability

Risk factors for COPD:

1. SMOKING

2. ETS, PIPE, Cigar

3. Air polution

4. Factors that affect lung growth during childhood

5. Hereditary deficiency of Alpha-1 antitrypsin

Chronic inflammatory process in peripheral airways and lung parenchyma--

Inflammatory mediators cause progressive changes in small airways and parenchyma that contributes to obstructiion

Cough

Sputum production

Dyspnea on exertion

Episodes of acute worsening of symptoms: exacerbations

1. Three Classic symptoms

2. >40 yo

3. Confirmed with spirometry

I. Mild

II. Moderate

III. Severe

IV. Very Severe

As disease progresses airflow irritation worsens

1. Smoking cessation

2. Relieve symptoms

3. Prevent disease progression

4. Improve exercise tolerance and health status

5. Prevent and treat complications and exacerbations

6. reduce mortality

7. Prevent or minimize side effects from treatment

1. Assess and monitor disease (PFT's)

2. Reduce risk factors

3. Manage stable COPD

4. Manage exacerbations

Cornerstone of therapy for COPD:

Results

Smoking cessation

Slows the progression of COPD - reduces the reate of decline in lung function and can prevent COPD if quit early enough

Non pharmacological therapy

Pulmonary rehabilitations:

1. Smoking cessation

2. Exercise training

3. Nutrition Counseling

4. Education

1. Increases quality of sleep

2. Improves intellectual funx, dec memory loss, improves depression

3. Improves survival and quality of life if used for 16-24hr/d

1. Pa02 <55 or O2 Sat <88%

2. PaO2 55-60mmhg or o2sat is 88% - if there is evidence of pulm hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (hematocit >55%)

1. bullectomy and lung transplantation- stage IV

2. insufficient evidence for to support for lung volume reduction surgery

1. Dec cyclic GMP with --> bonchial muscle relaxation

2. > degree of bronchodilation like B2 agonsists with fewer systemic side effects

3. Slower onset of action and longer duration of action than B2

4. Not absorbed systemically

Dry mouth

metallic taste

Atrovent HFA (Ipratropium)

2 puffs qid (up to 12 inhalations/24hrs)

Available MDI or neb-

Mdi peak 1.5-2hrs, duration 4-6hrs

long acting anticholinergic bronchodilator

(Maintenance therapy-NOT for acute symptoms)

Tiotropium (Spiriva)

18 mcg inhaled via DPI qd

peak- 1.5-3hr

duration- >24hrs

Pts with CrCl <50ml/min should be closely monitored

1. inhalation route is preferred for efficacy and safety

2. proper inhlation requires good technique and safety

3. some patients may respond to higher than usual doses

Albuterol MDI (Proventil or Ventolin)

1-2 puffs q4-6hr prn max 12 puffs/24hr

Salmeterol MDI (Serevent) 1 inhalation q12hrs

Formoterol (Foradil) 12mcg (1 capsule) by DPI inhalation q12hrs

Arformoterol (Brovana) 15mcg neb q 12hrs

Fixed dose invailable:

Combivent MDI (ipratropium + albuterol) 2 puffs qid

may improve efficacy and dec. the risk of side effects compared to increasing the dose of a single bronchodilator

Methlyxanthine Bronchodilator: Theophylline

MOA

Blocks phosphodiesterase which inc cAMP. Relaxes smooth muscle of bronchi and pulmonary blood vessel.

Stimulates respiratory center and enhances active daily living in patients with severely limitaing COPD. May be beneficial for nocturnal dyspnea.

Metabolism by liver, excreted by kidney

Plasma t1/2 shorter in smokers, clearance dec in elderly

slow onset of action - not for acute symptoms

Dosed once or twice daily

MANY drug interactions

Need to monitor levels regularly (8-12mg/L norm)

Restlessness, insomnia, GERD during sleep, palpatations, potentiation of diuresis

>20mg/L adverse rxns: N,V, D, h/A, insomnia, irritability

>35mg/L: Hyperglycemia, hypotension, atrial tachycardia, ventricular arrythmias, refractory seizures

Patients with FEV1<505% predicted and repeated exacerbationsn (3 in 3 yrs)

Inc treament of CSS is not recommmended- only relieves symps, does not modify the long-term decline in FEV1, and inc likelyhood of pneumonia

influenza vaccine (sept-nov) dec death 50%

pneumococcaa vaccine

(23-valent and covers 85% disease, for >65yo, or <65yo with <40% FEV1)

Not recommended only for infectious exacerbations and other bacterial infections - 1/3 viral, when bacteria ususal:

S. pneumonia

H. influenza

M. catarrhalis

Active reduction of risk factors including flu vaccine

Short acting bronchodilator-when needed

Flu Vacc (reduce risk factors)

short acting bronchodilator and

regular treatment of long-acting bronchodilators

add rehabilitation

Flu Vacc (reduce risk factors)

short acting bronchodilator and

regular treatment of long-acting bronchodilators

add rehabilitation and

inhaled glucocorticosteroid if repeated exacerbation

Flu Vacc (reduce risk factors)

short acting bronchodilator and

regular treatment of long-acting bronchodilators

add rehabilitation and

inhaled glucocorticosteroid if repeated exacerbation

Add: long term O2 if chronic resp. failure

CONSIDER surgical treatment

inc dose and or freq of existing short-acting bronchodilator tx. preferably with B2-agonists

add anticholinergics until syms improve-if not already used

Presence of 3 cardial symptoms:

inc dyspnea

inc sputum vol

inc sputum purulence

or inc sputum purulence + one cardial symptom + on mechanical ventilation

inc intensity of symp-dyspnea at rest

severe background COPD

new physical signs

failure of exacerbations to respond to therapy

significant comorbidities

new arrhythmias

freq exacerbations

diagnostic uncertainty

old age

insufficient home support

1. Assess severity of symptoms, blood gases, chest xray

2. admin controlled o2 and repeat art. blood gas after 30-60 min

3.bronchodilators

4. Add glucocorticosteroids

5. consider Antibx if symptoms

6. At all times: monitor fluid and nutrition, SQ heparin, treat associated conditions, closely monitor patient

1. HTN

2. Osteoporosis

3. immunosupression