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Lower Respiratory Disease
 
Lower Respiratory Disease
 

Chronic Obstructive Pulmonary Disease

 
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Overview

  • Chronic obstructive pulmonary disease is a severely functionally limiting condition primarily affecting previous tobacco smokers. Management is targeted to the severity of the disease, and underpinned by smoking cessation.

Pathogenesis

    • Risk Factors for COPD

    • Smoking
    • Occupational exposure - coal, toluene (plastics)
    • Environmental air pollution
    • Alpha-1 antitrypsin deficiency

Manifestations

    • Complications of COPD

    • Disease-Related

    • Pneumonia
    • Cor pulmonale
    • Pulmonary hypertension
    • Pneumothorax
    • Respiratory failure
    • Polycythaemia
    • Treatment-Related

    • Cushing’s syndrome (steroids)
    • Oral candidiasis (steroids)
    • Tremor (beta agonists)

Diagnosis

    • Signs of Chronic Obstruction Pulmonary Disease

    • General Signs

    • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
    • Barrel chest (emphysema)
    • Tar-stained fingers (smoking)
    • Asterixis (CO2 retention)
    • Reduced chest expansion
    • Reduced breath sounds
    • Wheeze
    • Signs of Complications

    • Infective exacerbation - fevers, green sputum
    • Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
    • Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
    • Polycythaemia - polycythaemic facies
    • Steroid complications - Cushing’s syndrome, oral candidiasis
    • Signs of Management

    • Oxygen
    • Inhalers
    • Lung transplant scar
    • Chest X-Ray Signs of Emphysema

    • Hyperinflation - hyperlucency of lung fields, diaphragmatic flattening, mediastinal narrowing
    • Bullae
    • Lung scarring
    • Examples

    • Hyperinflation in a patient with emphysema
    • Hyperinflation in a patient with emphysema
       
    • Hyperinflation with multiple right apical bullae
    • Hyperinflation with multiple right apical bullae
       

Management

    • Management Strategies

    • Lifestyle Measures

    • Smoking cessation
    • Pulmonary rehab
    • Nutritional support
    • Develop social support
    • Pharmacologic

    • Long-acting beta agonists (LABAs) - salmeterol, formoterol, indacaterol
    • Long-acting anti-muscarinic agents (LAMAs) - tiotropium, aclidinium, umeclidinium, glycopyrronium
    • LAMA / LABA combinations - tiotropium / olodaterol, aclidinium / formoterol, glycopyrronium / indacaterol, umeclidinium / vilanterol
    • Inhaled corticosteroid (ICS) / LABA combinations - budesonide / formoterol, fluticasone / salmeterol, fluticasone / formoterol, fluticasone / vilanterol
    • LAMA / LABA / ICS combination - fluticasone / umeclidinium / vilanterol
    • Supportive Measures

    • Home oxygen
    • Vaccinations - influenza, pneumococcal
    • Surgical Options

    • Lung volume reduction surgery
    • Lung transplantation
  •  
    Respiratory Medications
    • Pearls

    • Smoking cessation has the greatest ability to influence the course of COPD
    • Tailor pharmacologic options to the severity of disease
    • Ensure that the patient has an exacerbation management plan in place
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