martes, 6 de noviembre de 2018

Chronic Obstructive Pulmonary Disease Management

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By Ananya Mandal, MDReviewed by April Cashin-Garbutt, MA (Cantab)

Chronic obstructive pulmonary disease (COPD) is one of the commonest lung problems affecting middle aged smokers. The management aims include:-

identification and staging of patients with COPD with the help of spirometry
drawing up a care plan
following up patients regularly after diagnosis - at least twice yearly
treating co-existing diseases that commonly occur in patients with COPD
slow and prevent the progression of lung damage and COPD pathology mainly by lifestyle changes like smoking cessation
reducing and eliminating breathlessness and other respiratory symptoms with the help of medications
improving quality of life and capacity for physical activity
reducing frequency and severity of exacerbations and treating them appropriately
improving overall health
reducing risk of death due to COPD

The approaches to a patient with COPD thus have both medication as well as non-pharmacological therapy.

Lifestyle changes

Smoking is the most important cause of and contributing factor for COPD progression. Thus stopping smoking completely is the most important factor in slowing the progression of COPD. Cessation of smoking benefits even long term smokers. Smoking cessation may be achieved by pharmacological measures like nicotine replacement therapy etc.

Incorporation of healthy lifestyle habits including a healthy balanced diet as well as regular physical exercise. Patients are encouraged to avoid dust, air pollutants, exposure to second hand smoke etc.

Pulmonary rehabilitation programs

Pulmonary rehabilitation program may be suggested in patients living in areas where community respiratory services are available.

Pharmacologic management

The main treatment is with the use of bronchodilators. These are usually beta 2 agonists or inhaled agents that lead to opening up of the narrowed airways and thus provide relief from breathlessness.

Medications used in COPD are mainly for relief of the symptoms. These agents have not been shown to reverse, slow, or prevent progressive decline in lung function. They can, however, improve symptoms, reduce exacerbations and hospitalizations, and improve quality of life. Inhalation technique may take time to master. Patient needs to be monitored carefully for correct inhalation technique for optimum benefits from the medications.

Patients with mild COPD are usually prescribed a short-acting inhaled beta2 agonist like Salbutamol or are given an antimuscarinic inhaled agent like ipratropium to be used as needed. Mucolytic medicine is given as tablets or syrup and makes sputum thinner and runnier, making it easier to cough up.

If there are persistent symptoms the patient is advised regular use of ipratropium or a long-acting antimuscarinic agent tiotropium or long-acting beta2 agonist (LABA) like Salmeterol, Formoterol etc. Concurrent use of tiotropium and ipratropium is not recommended.

For patients with moderate to severe COPD with a history of exacerbations that occur more than one per year on average, for two consecutive years, inhaled corticosteroids may be advised. These can be used regularly in combination with tiotropium and LABA therapy to reduce exacerbations. Long term oral corticosteroid therapy is not recommended.

Patients with persistent symptoms despite optimal inhaled therapy may be advised another group of bronchodilators called Theophylline. These may be given as pills.

Continued care

Continued care involves a more wholesome care of patients with COPD. This includes:-

immunization against influenza with annual influenza vaccination
immunizations against pneumococcal infections at least once and repeated in 5-10 years
oxygen therapy to maintain the normal blood levels of oxygen. The goal of oxygen therapy is to maintain PaO2 ≥ 60 mmHg or SpO2 ≥ 90% at rest. Oxygen therapy may be a useful addition to exercise therapy and pulmonary rehabilitation.

Management of acute exacerbations of COPD

This is typically characterized by sustained (indicating persistent symptoms for 48 hours or more) worsening of cough and shortness of breath with or without sputum. The commonest cause is a chest infection caused by virus or bacteria.

Therapy includes:-

therapy with short-acting beta2 agonists and antimuscarinic bronchodilators preferably given as inhalation
oral corticosteroids like prednisone 25-50 mg/day for less than two weeks in moderate to severe cases
antibiotics for bacterial infections
management of co-existing conditions and complications
non-invasive ventilation (NIV) that involves pumping oxygen through a nasal cannula or a mask and into the lungs

Lung surgery for COPD

Some people with severe COPD may be offered surgery on their lungs. The surgery basically involves removal of a large air pocket (called a 'bulla'), or part of the lung. Lung transplantation is a high-risk operation and is only suitable for a small number of people.

End of life care in advanced patients

This mainly focuses on treatment of symptoms and improving the quality of life as much as possible. Home oxygen and treatment for severe breathlessness may be needed with opioids, neuroleptics and benzodiazepines. BiPAP (bilevel positive airway pressure device) and other pulmonary rehabilitation devices may be used.