Management of Chronic obstructive pulmonary disease
Chronic bronchitis and emphysema should be considered together as
both these conditions usually coexist to some degree in each patient. An
alternative, and preferable, term—chronic obstructive airway or pulmonary
disease (COPD)—is used to cover chronic bronchitis and emphysema with
chronic airfl ow limitation.
Factors in causation
• cigarette smoking: usu. 20/d for 20 yrs
• air pollution
• airway infection
• familial factors: genetic predisposition
• alpha1-antitrypsin defi ciency (emphysema)
Symptoms
• onset in 5th or 6th decade
• excessive cough
• sputum production (chronic bronchitis)
• dyspnoea (chronic airfl ow limitation)
• wheeze (chronic bronchitis)
• chest tightness
• susceptibility to colds
Investigations
Chest X-ray : can be normal (even with advanced disease) but characteristic
changes occur late in disease.
Pulmonary function tests (spirometry is gold standard):
• peak expiratory fl ow rate—low with minimal response to
bronchodilator (not sensitive)
• ratio FEV1/FVC—reduced with minimal response to bronchodilator
• gas transfer coeffi cient of CO is low if signifi cant emphysema
Blood gases:
• may be normal
• PaCO2 ↑ ; PaO2 ↓ (advanced disease)
COPD is defi ned as post-bronchodilator FEV1/FVC of <0.70 (<70%) and
FEV1 <80% predicted.
Management
Advice to the patient
• If you smoke, you must stop: this is the key to management.
• Avoid places with polluted air and other irritants, such as smoke, paint
fumes and fi ne dust.
• Go for walks in clean, fresh air.
• A warm dry climate is preferable to a cold damp place (if prone to
infections).
• Get adequate rest.
• Avoid contact with people who have colds and fl u.
Physiotherapy
Refer to a physiotherapist for chest physiotherapy, breathing exercises and
an aerobic physical exercise program.
Drug therapy
Consider the use of bronchodilators (e.g. inhaled β2-agonists—ipratropium
bromide, tiotropium) and inhaled corticosteroids, because of associated
(often unsuspected) asthma. A carefully monitored trial of these drugs
with FEV measurement is recommended. Fixed dose combinations of
LABA and inhaled corticosteroids (Seretide or Symbicort) may be used for
patient convenience.
Corticosteroids should be used routinely for acute exacerbations. Use:
• prednisolone 30–50 mg (o)/d
If not tolerated orally use
• hydrocortisone 100 mg IV 6 hrly (or equivalent dose of alternative
steroid)
The indication for antibiotic treatment is:
• ↑ cough and dyspnoea plus
• ↑ sputum volume and/or purulence
Use:
• amoxycillin 500 mg (o) tds for 5 d or
• doxycycline 200 mg (o) statim then 100 mg/d for 5 d
Stage of COPD Treatment
0 At risk • Avoidance of risk factors esp. smoking
• Influenza & pneumococcal vaccination
?Haemophilus infl uenzae vaccination
1 Mild • Add short-acting bronchodilator
2 Moderate • Add one of more bronchodilators inc. long-acting
bronchodilator
• Add pulmonary rehabilitation
3 Severe • Add inhaled corticosteroids
4 Very severe • Add long-term O2 (if chronic respiratory failure)
• Consider surgical referral (?lung reduction or
transplantation)
COPD with dyspnoea
-smoking cessation
-short-actingbronchodilator
(inhalation verses nebuliser)
combination
beta agonist + ipratropium
long-acting beta agonist or tiotropium
(or use both)
inhaled corticosteroid
refer
COPD with acute exacerbation
-increase short acting bronchodilators
-beta agonist and ipratropirum bromide
-check smoking
-check inhaler device / technique
-oral corticosteroids
-antibiotics
-oxygen if hypoxemic
-refer
Chronic bronchitis and emphysema should be considered together as
both these conditions usually coexist to some degree in each patient. An
alternative, and preferable, term—chronic obstructive airway or pulmonary
disease (COPD)—is used to cover chronic bronchitis and emphysema with
chronic airfl ow limitation.
Factors in causation
• cigarette smoking: usu. 20/d for 20 yrs
• air pollution
• airway infection
• familial factors: genetic predisposition
• alpha1-antitrypsin defi ciency (emphysema)
Symptoms
• onset in 5th or 6th decade
• excessive cough
• sputum production (chronic bronchitis)
• dyspnoea (chronic airfl ow limitation)
• wheeze (chronic bronchitis)
• chest tightness
• susceptibility to colds
Investigations
Chest X-ray : can be normal (even with advanced disease) but characteristic
changes occur late in disease.
Pulmonary function tests (spirometry is gold standard):
• peak expiratory fl ow rate—low with minimal response to
bronchodilator (not sensitive)
• ratio FEV1/FVC—reduced with minimal response to bronchodilator
• gas transfer coeffi cient of CO is low if signifi cant emphysema
Blood gases:
• may be normal
• PaCO2 ↑ ; PaO2 ↓ (advanced disease)
COPD is defi ned as post-bronchodilator FEV1/FVC of <0.70 (<70%) and
FEV1 <80% predicted.
Management
Advice to the patient
• If you smoke, you must stop: this is the key to management.
• Avoid places with polluted air and other irritants, such as smoke, paint
fumes and fi ne dust.
• Go for walks in clean, fresh air.
• A warm dry climate is preferable to a cold damp place (if prone to
infections).
• Get adequate rest.
• Avoid contact with people who have colds and fl u.
Physiotherapy
Refer to a physiotherapist for chest physiotherapy, breathing exercises and
an aerobic physical exercise program.
Drug therapy
Consider the use of bronchodilators (e.g. inhaled β2-agonists—ipratropium
bromide, tiotropium) and inhaled corticosteroids, because of associated
(often unsuspected) asthma. A carefully monitored trial of these drugs
with FEV measurement is recommended. Fixed dose combinations of
LABA and inhaled corticosteroids (Seretide or Symbicort) may be used for
patient convenience.
Corticosteroids should be used routinely for acute exacerbations. Use:
• prednisolone 30–50 mg (o)/d
If not tolerated orally use
• hydrocortisone 100 mg IV 6 hrly (or equivalent dose of alternative
steroid)
The indication for antibiotic treatment is:
• ↑ cough and dyspnoea plus
• ↑ sputum volume and/or purulence
Use:
• amoxycillin 500 mg (o) tds for 5 d or
• doxycycline 200 mg (o) statim then 100 mg/d for 5 d
Stage of COPD Treatment
0 At risk • Avoidance of risk factors esp. smoking
• Influenza & pneumococcal vaccination
?Haemophilus infl uenzae vaccination
1 Mild • Add short-acting bronchodilator
2 Moderate • Add one of more bronchodilators inc. long-acting
bronchodilator
• Add pulmonary rehabilitation
3 Severe • Add inhaled corticosteroids
4 Very severe • Add long-term O2 (if chronic respiratory failure)
• Consider surgical referral (?lung reduction or
transplantation)
COPD with dyspnoea
-smoking cessation
-short-actingbronchodilator
(inhalation verses nebuliser)
combination
beta agonist + ipratropium
long-acting beta agonist or tiotropium
(or use both)
inhaled corticosteroid
refer
COPD with acute exacerbation
-increase short acting bronchodilators
-beta agonist and ipratropirum bromide
-check smoking
-check inhaler device / technique
-oral corticosteroids
-antibiotics
-oxygen if hypoxemic
-refer