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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
  • 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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