NIMISHA

GUPTA, MPTh

COPD
COPD is a preventable and treatable disease with some extra pulmonary effects that may contribute to the severity in individual patients. It is a disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is both progressive and associated with an abnormal inflammatory response to noxious stimuli.

GLOBAL STATISTICS
Third

most common cause of certified illness in UK (Gravil et al,1998). Fifth greatest cause of disability. (WHO 1996). Only major cause of death increasing in prevelance.(Oh,1997) Largely preventable.(Huib,1999)

RISK FACTORS
WHAT CAUSES COPD ?

HOST FACTORS
Hyperactivity

of airways . Overall lung growth. Genetics alpha-1 antitrypsin deficiency. - inflammatory mediated genes.

ENVIRONMENTAL FACTORS
Tobacco

smoke Occupational dusts and chemicals. Indoor air pollutants. Outdoor air pollutants.

COPD CHRONIC BRONCHITIS EMPHYSEMA OTHER OBSTRUCTIVE DISEASES ASTHMA BRONCHIECTASIS CYSTIC FIBROSIS

OBSTRUCTIVE PULMONARY DISEASES American Thoracic Society

PATHOPHYSIOLOGY

CHRONIC BRONCHITIS
REPEATED INHALATION OF TOBACCO SMOKE
IRRITATION OF AIRWAY LINING AND MUCOUSAL DAMAGE

INFLAMMATION

MUCOUS HYPERSECRETION

BRONCHOSPASM

NARROWING OF DISTAL AIRWAYS

LITTLE AIRWAY OBSTRUCTION

DUE TO STIMULATION OF PSNS

CHRONIC INFLAMMATION

Ach RELEASE

FIBROTIC CHANGES AND SCARING

BREATHLESSNESS

EMPHYSEMA
PRIMARY EMPHYSEMA Congenital lack of alpha-anti-trypsin Protein Breakdown

SECONDARY EMPHYSEMA Alveolar damage due to smoking

Erosion of alveolar septa

Dilatation of distal airspaces

Destruction of elastic fibres

Floppy airways collapse

MECHANISM OF AIRWAY OBSTRUCTION

PROGRESSION OF COPD

PATTERN OF COPD

BLUE AND BLOATED

1.
2. 3. 4. 5. 6. 7.

Pt. has following symptoms: Obesity. Mild Dyspnoea. Copious Sputum. Low Po2 and high Pco2. Central Cyanosis with core pulmonale. Peripheral Edema. Increased residual volume, normal TLC.

PINK AND PUFFING

Pt. has following symptoms: 1.Thin ,anxious expression, severe breathlessness 2.Little or no sputum production 3. Relatively normal Po2 and Pco2. 4. Central cyanosis, no cor pulmonale. 5. No peripheral edema 6. Increased TLC due to hyperventilation

STAGES OF COPD
Stage 0: At risk I: Mild Characterstics Normal spirometry Chronic symptoms (cough, sputum) FEV1/FVC < 70%; FEV1 80% predicted With or without chronic symptoms (cough, sputum) FEV1/FVC < 70%; 50% FEV1 < 80% predicted With or without chronic symptoms (cough, sputum,dyspnea) FEV1/FVC < 70%; 30% FEV1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea) FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

II: Moderate

III: Severe

IV: Very Severe

CLINICAL PRESENTATION
Common signs and symptoms of COPD may include: Cough Sputum (mucus) production Shortness of breath, especially with exercise Wheezing (a whistling or squeaky sound when you breathe) Chest tightness.

For certain severe COPD symptoms, hospitalization may be required. These symptoms include: You have a lot of difficulty catching your breath You have a hard time talking Your lips or fingernails turn blue or gray You are not mentally alert Your heartbeat is very fast.

EVALUATION

Demographic data Chief complaints History 1 Present 2 Medical 3 Family 4 Personal & social

Observation
1. 2. 3. 4. 5. 6. 7. Dorsal kyphosis Barrel chest Decreased thoracic excursion Use of accessory muscles Cyanosis Digital clubbing Pursed lip breathing

Palpation
1.

2.

Pitting edema of LL. Hypertrophy of accessory neck muscle.

Examination
Auscultation

1. Breath sounds and heart sounds difficult to hear. 2. Breath sounds expiratory wheeze and crackles may be present.

 Measurement

of strength

1. peripheral 2. ventilatory muscles Neck vein distention during expiration.

INVESTIGATION
1.

2.
3. 4. 5. 6. 7.

Blood Analysis ECG Radiograph Sputum Analysis Blood gases PFT Non routine tests

Investigation
Serial domiciliary peak flow measurements Alpha-1 antitrypsin

Role
To exclude asthma if diagnostic doubt remains If early onset, minimal smoking history or family history

Transfer factor for carbon monoxide (TLCO) ECG

Echocardiogram Pulse oximetry

To investigate symptoms that seem disproportionate to the spirometric impairment To assess cardiac status if features of cor pulmonale To assess cardiac status if features of cor pulmonale
To assess need for oxygen therapy If cyanosis, or cor pulmonale present, or if FEV1 < 50% predicted

CT scan of the thorax

To investigate symptoms that seem disproportionate to the spirometric impairment To investigate abnormalities seen on a chest radiograph To assess suitability for surgery

Sputum culture

To identify organisms if sputum is persistently present and purulent

X-RAY INTERPRETATION
Lungs are enlarged so more than seven ribs can be counted Diaphragm Flat or scallop shaped instead of concave upward Heart- appear to swing in the wind

Bullae - densely black areas of lung, round, surrounded by hair line shadows Pulmonary arteries are large centrally consistent with developing sec. pul. arterial hypertension AP diameter increased

Think of the diagnosis of COPD for patients who are: over 35 smokers or ex-smokers have any of these symptoms: exertional breathlessness chronic cough regular sputum production frequent winter bronchitis wheeze and have no clinical features of asthma.

 Perform

likely. Airflow obstruction is defined as: FEV1 < 80% predicted And FEV1/FVC < 0.7 Spiro metric reversibility testing is not usually necessary as part of the diagnostic process or to plan initial therapy

spirometry if COPD seems

If still doubt about diagnosis consider the following pointers: Asthma may be present if: there is a > 400 ml response to bronchodilators serial peak flow measurements show significant diurnal or day-to-day variability there is a > 400 ml response to 30 mg prednisolone daily for 2 weeks Clinically significant COPD is not present if FEV1 and FEV1/FVC ratio return to normal with drug therapy. Refer for more detailed investigations if needed If still in doubt, make a provisional diagnosis and start empirical treatment
If no doubt, diagnose COPD and start treatment Reassess diagnosis in view of response to treatment

Clinical features differentiating COPD and asthma

COPD Smoker or ex-smoker Symptoms under age 35 Chronic productive cough Breathlessness Night-time waking with breathlessness and/or wheeze Significant diurnal or day-to-day variability of symptoms Nearly all Rare Common Persistent and progressive Uncommon Asthma Possibly Common Uncommon Variable Common

Uncommon

Common

MANAGEMENT

MEDICAL

Smoking Cessation Initial small recovery in FEV1 Pharmacological management Maintenance 1.Anti- cholinergics 2.Long acting beta 2 agonist 3.Steroids 4.Cromolyn Na 5.Leucoterine receptor antagonist Rescue 1.Short acting beta 2 agonist

 Antibiotics

Supplemental

oxygen

SURGICAL
Bullectomy

Lung

volume reduction surgery Lung Transplantation

PHYSIOTHERAPY

GOALS AND OUTCOMES

Maximize the patients quality of life. Educate the patient. Facilitate mucociliary transport. Optimize secretion clearance Optimize alveolar ventilation. Optimize lung volume and capacities and flow rates Reduce work of breathing & heart. Optimal physical endurance and exercise capacity.

Pulmonary rehabilitation

Patient

Education

Secretion Removal Technique

Hydration

& humidification Postural drainage Manual technique Percussion Vibration FET-coughing, huffing Breathing tech.-ACBT,AD.

 Mechanical

aidsPEP Cornet Precursors Vibrators IPPV Suctioning

WORK OF BREATHING
1.

2.

3.

4. 5.

Excess work of breathing is required to: Overcome the resistance of obstructed airways Assist expiration which becomes active rather than passive Sustained inspiratory mscl. Action throughout the respiratory cycle Hoovers sign Compensate for the loss of bucket handle movement of ribs

Reducing The Work Of Breathing

Sleep

& Rest. Positioning Relaxation Breathing Re-education Tips on reducing breathlessness Pacing Mechanical- Noninvasive ventilation by nasal mask

NON INVASIVE VENTILATION BY NASAL MASK

EXERCISE TRAINING
Aerobic

training Strength Training Exercise Progression Program Duration

Exercise Prescription
Incorporates 4 variables these being : 1.MODE a) LE activities walking jogging cycling swimming b) UE ergo meter c) circuit approach 2.INTENSITY a) exercise intensity as % of Vo2 max b) exercise intensity as % of heart rate reserve c) exercise intensity by rating perceived exertion 3.DURATION a) 20 30 minutes interspersed with rest 4.FREQUENCY a) 3-5 sessions per week

INSPIRATORY MUSCLE TRAINING

Flow dependent inspiratory muscle trainer Pressure threshold muscle trainer

ENERGY CONSERVATION
ADLS

Stress

reduction Mechanical rest

GOALS FOR HOME CARE

Understand

disease Be compliant with medications & health precautions Learn preventive care Learn ventilator58 strategies to increase comfort & function Learn to monitor for signs of impending trouble

the dysfunction or

 Train

to pace activity & use energy conservation techniques & rest periods Maintain proper nutrition & hydration Develop a support network Maintain walking program and general exercises.

Patient with stable COPD

Assess symptoms/problems and manage as described below Patients with COPD should have access to multidisciplinary team Breathlessness and exercise limitation Smoking Use short-acting bronchodilator as needed Offer help to stop (beta2-agonist or anticholinergic) smoking at every opportunity If still symptomatic try combined therapy with Combine a short-acting beta2-agonist and a short-acting pharmacotherapy with anticholinergic appropriate support as part of a programme If still symptomatic use a long-acting bronchodilator (beta2-agonist or anticholinergic) In moderate or severe COPD: if still symptomatic consider a trial of a combination of a long-acting beta2-agonist and inhaled corticosteroid discontinue if no benefit after 4 weeks If still symptomatic consider adding theophylline Offer pulmonary rehabilitation to all patients who consider themselves functionally disabled (usually MRC grade 3 and above)

Consider referral for surgery: bullectomy, lung volume reduction, transplantation

Frequent exacerbations

Respiratory failure

Cor pulmonale

Offer annual influenza vaccination Offer pneumococcal vaccination Give self-management advice Optimize bronchodilator therapy with one or more long-acting bronchodilator (beta2-agonist or anticholinergic) Add inhaled corticosteroids if FEV1 50% and two or more exacerbations in a 12-month period (NB these will usually be used with long-acting bronchodilators)

Assess for apt. oxygen long term ambulatory short burst

Consider referral for assessment For long term domiciliary NIV Abnormal BMI

Assess need for Oxygen Use diuretics

Chronic productive cough

Consider trial of Refer for dietetic mucolytic therapy advice Continue if symptomatic Give nutritional improvement supplements if the BMI is low Anxiety and depression Be aware of anxiety & depression &screen for them in those most physically disabled Treat with conventional pharmacotherapy

EXACERBATION OF COPD
Exacerbations

of COPD can be associated with increased: Dyspnoea sputum purulence sputum volume
cough

Initial management Increase frequency of bronchodilator use consider giving via a nebuliser Oral antibiotics if purulent sputum Prednisolone 30 mg daily for 714 days for all patients with significant increase in breathlessness, and all patients admitted to hospital, unless contraindicated

Hospital

Decide where to manage

Home

FACTORS
Able to cope at home Breathlessness
General condition

HOME YES mild good good no yes normal No Good

HOSPITAL NO severe poor

Confined to bed

Level of activity
CYANOSIS
Worsening peripheral edema Level of consciousness Already receiving LTOT Social circumstances

yes no impaired Yes

Living alone

Acute confusion

No

Yes

Rapid rate of onset Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes

No No

Yes Yes

SaO2 < 90%

Changes on the chest radiograph

No No >7.35 >7kpa

Yes Present <7.35 <7kpa

Arterial pH level

Arterial PaO2

HOSPITAL MANAGEMENT

Investigations Chest X-ray Arterial blood gases (record inspired oxygen concentration) ECG Full blood count and urea and electrolytes Theophylline level if patient on theophylline at admission Sputum microscopy and culture if purulent Further management Give oxygen to keep SaO2 above 90% Assess need for non-invasive ventilation: consider respiratory stimulant if NIV not available assess need for intubations Consider intravenous theophylline if poor response to nebulised bronchodilators

Consider hospital-at-home or assisted-discharge scheme

Before discharge Establish on optimal therapy Arrange multidisciplinary assessment if necessary

Home

Investigations Sputum culture not normally recommended Pulse oximetry if severe exacerbation

Further management Arrange appropriate review Establish on optimal therapy Arrange multidisciplinary assessment if necessary

Discharge planning
1 Spirometry should be measured in all patients before discharge. 2 Patients should be re-established on their optimal maintenance bronchodilator therapy before discharge. 3 Patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge
4 All aspects of the routine care that patients receive (including appropriateness & risk side effects ) should be assessed before discharge.

5 Patients should be given appropriate information to enable them to fully understand the correct use of medication, including oxygen, before discharge. 6 Arrangements for follow-up and home care (such as visiting nurse ,oxygen delivery, referral for other support) should be made before discharge.
7 Before the patient is discharged, the patient, family and physician should be confident that he or she can manage successfully. When there is remaining a doubt formal activities of daily living assessment may be helpful.

BIBLIOGRAPHY
DONNA FROWNFELTER PHYSICAL REHABLITATION SULLIVAN PHYSIOTHERAPY IN RESPIRATORY CARE HOUGH TIDYS PHYSIOTHERAPY NICE CLINICAL GUIDELINE 12(FEB 2004) GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE , 2008 HILLEGASS CLINICAL EXERCISE PHYSIOLOGY : LeMaru