COPD Home Visit (Chronic Obstructive Pulmonary Disease) Session 7

7 Days validity - 1 per day

What is this package about?

Chronic obstructive pulmonary disease (COPD)

Have symptoms of chronic bronchitis and emphysema, but the classic triad also includes asthma.

Chronic bronchitis is defined clinically as the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded). Emphysema is defined pathologically as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

Signs and symptoms:

Patients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. Symptoms include the following:

- Cough, usually worse in the mornings and productive of a small amount of colorless sputum

- Acute chest illness

Breathlessness: The most significant symptom, but usually does not occur until the sixth decade of life

Wheezing: May occur in some patients, particularly during exertion and exacerbations

The sensitivity of physical examination in detecting mild to moderate COPD is relatively poor, but physical signs are quite specific and sensitive for severe disease. Findings in severe disease include the following:

- Tachypnea and respiratory distress with simple activities

- Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces (Hoover sign)

- Cyanosis

- Elevated jugular venous pulse (JVP)

- Peripheral edema

Thoracic examination reveals the following:

- Hyperinflation (barrel chest)

- Wheezing - Frequently heard on forced and unforced expiration

- Diffusely decreased breath sounds

- Hyperresonance on percussion

- Prolonged expiration

- Coarse crackles beginning with inspiration in some cases

- Certain characteristics allow differentiation between disease that is predominantly chronic bronchitis and that which is predominantly emphysema. Chronic bronchitis characteristics include the following:

Patients may be obese:

- Frequent cough and expectoration are typical

- Use of accessory muscles of respiration is common

- Coarse rhonchi and wheezing may be heard on auscultation

- Patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis

Emphysema characteristics include the following:

- Patients may be very thin with a barrel chest

- Patients typically have little or no cough or expectoration

- Breathing may be assisted by pursed lips and use of accessory respiratory muscles; patients may adopt the tripod sitting position

- The chest may be hyperresonant, and wheezing may be heard

- Heart sounds are very distant

- Overall appearance is more like classic COPD exacerbation

- Diagnosis

The formal diagnosis of COPD is made with spirometry; when the ratio of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) is less than 70% of that predicted for a matched control, it is diagnostic for a significant obstructive defect. Criteria for assessing the severity of airflow obstruction (based on the percent predicted post bronchodilator FEV1) are as follows:

- Stage I (mild): FEV 1 80% or greater of predicted

- Stage II (moderate): FEV 1 50-79% of predicted

- Stage III (severe): FEV 1 30-49% of predicted

- Stage IV (very severe): FEV 1 less than 30% of predicted or FEV 1 less than 50% and chronic respiratory failure

Arterial blood gas (ABG) findings are as follows:

- ABGs provide the best clues as to acuteness and severity of disease exacerbation

- Patients with mild COPD have mild to moderate hypoxemia without hypercapnia

As the disease progresses, hypoxemia worsens and hypercapnia may develop, with the latter commonly being observed as the FEV 1 falls below 1 L/s or 30% of the predicted value pH usually is near normal; a pH below 7.3 generally indicates acute respiratory compromise. Chronic respiratory acidosis leads to compensatory metabolic alkalosis. In patients with emphysema, frontal and lateral chest radiographs reveal the following:

- Flattening of the diaphragm

- Increased retrosternal air space

- A long, narrow heart shadow

- Rapidly tapering vascular shadows accompanied by hyperlucency of the lungs

- Radiographs in patients with chronic bronchitis show increased bronchovascular markings and cardiomegaly

Advantages of high-resolution CT include the following:

- Greater sensitivity than standard chest radiography

- High specificity for diagnosing emphysema (outlined bullae are not always visible on a radiograph)

- May provide an adjunctive means of diagnosing various forms of COPD (eg, lower lobe disease may suggest alpha1-antitrypsin (AAT) deficiency

- May help the clinician determine whether surgical intervention would benefit the patient

Other tests are as follows:

* Hematocrit - Patients with polycythemia (hematocrit greater than 52% in men or 47% in women) should be evaluated for hypoxemia at rest, with exertion, or during sleep

* Serum potassium - Diuretics, beta-adrenergic agonists, and theophylline act to lower potassium levels

* Measure AAT in all patients younger than 40 years or in those with a family history of emphysema at an early age

* Sputum evaluation will show a transformation from mucoid in stable chronic bronchitis to purulent in acute exacerbations

* Pulse oximetry, combined with clinical observation, provides instant feedback on a patient's status

* Electrocardiography can help establish that hypoxia is not resulting in cardiac ischemia and that the underlying cause of respiratory difficulty is not cardiac in nature

* The distance walked in 6 minutes (6MWD) is a good predictor of all-cause and respiratory mortality in patients with moderate COPD [2, 3] ; patients with COPD who desaturate during the 6MWD have a higher mortality rate than do those who do not desaturate

* Two-dimensional echocardiography can screen for pulmonary hypertension

* Right-sided heart catheterization can confirm pulmonary artery hypertension and gauge the response to vasodilators

Management:

Smoking cessation continues to be the most important therapeutic intervention for COPD. Risk factor reduction (eg, influenza vaccine) is appropriate for all stages of COPD. Approaches to management by stage include the following:

- Stage I (mild obstruction): Short-acting bronchodilator as needed

- Stage II (moderate obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation

- Stage III (severe obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbations

- Stage IV (very severe obstruction or moderate obstruction with evidence of chronic respiratory failure): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbation; long-term oxygen therapy (if criteria met); consider surgical options such as lung volume reduction surgery (LVRS) and lung transplantation

Agents used include the following:

- Short-acting beta 2 -agonist bronchodilators (eg, albuterol, metaproterenol, levalbuterol, pirbuterol)

- Long-acting beta 2 -agonist bronchodilators (eg, salmeterol, formoterol, arformoterol, indacaterol, vilanterol)

- Respiratory anticholinergics (eg, ipratropium, tiotropium, aclidinium)

- Xanthine derivatives (ie, theophylline)

- Phosphodiesterase-4 Inhibitors (ie, roflumilast)

- Inhaled corticosteroids (eg, fluticasone, budesonide)

- Oral corticosteroids (eg, prednisone)

- Beta 2 -agonist and anticholinergic combinations (eg, ipratropium and albuterol, umeclidinium bromide/vilanterol inhaled)

- Beta 2 -agonist and corticosteroid combinations (eg, budesonide/formoterol, fluticasone and salmeterol, vilanterol/fluticasone inhaled)

Pulmonary rehabilitation programs are typically multidisciplinary approaches that emphasize the following:

- Patient and family education

- Smoking cessation

- Medical management (including oxygen and immunization)

- Respiratory and chest physiotherapy

- Physical therapy with bronchopulmonary hygiene, exercise, and vocational rehabilitation

- Psychological support form physiotherapist 

Indications for admission for acute exacerbations include the following:

- Failure of outpatient treatment

- Marked increase in dyspnea

- Altered mental status

- Increase in hypoxemia or hypercapnia

- Inability to tolerate oral medications such as antibiotics or steroids