Chronic obstructive pulmonary disease - Revision history

Aidan: /* GOLD Classification */

2021-10-21T15:51:32Z

GOLD Classification

← Older revision		Revision as of 15:51, 21 October 2021
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	**Pulmonary rehabilitation (improves survival if within 4 weeks of exacerbation)		**Pulmonary rehabilitation (improves survival if within 4 weeks of exacerbation)
	*Step-wise puffers: note that no puffers improve survival		*Step-wise puffers: note that no puffers improve survival
	**Short-acting anticholinergic bronchodilators prn: ipratropium/salbutamol		**Short-acting anticholinergic bronchodilators prn: [[ipratropium]]/[[salbutamol]]
	**Long-acting anticholinergic bronchodilators: tiotropium		**Long-acting anticholinergic bronchodilators: [[tiotropium]] (Spiriva)
	**Long-acting beta-agonist: salmeterol or formoterol		**Long-acting beta-agonist: [[salmeterol]] or [[formoterol]]
	**Inhaled corticosteroid (ICS): decreases frequency of exacerbations, but increases risk of pneumonia		**Inhaled corticosteroid (ICS): decreases frequency of exacerbations, but increases risk of pneumonia
			**Combination puffers include [[fluticasone]]/[[salmeterol]] (Advair)
	*Home oxygen		*Home oxygen
	**Improves survival if:		**Improves survival if:
	***Resting PaO2 < 55mmHg		***Resting PaO2 < 55mmHg
	***Resting PaO2 < 60mmHg plus cor pulmonale		***Resting PaO2 < 60mmHg plus cor pulmonale
	**Target SpO<s>2</s> >90%		**Target SpO<sub>2</sub> >90%
	**May not improve dyspnea		**May not improve dyspnea
	*If frequent exacerbations, consider roflumilast or azithromycin or NAC		*If frequent exacerbations, consider [[roflumilast]] or [[azithromycin]] or [[NAC]]
	*If daytime pCO<s>2</s> >52 mmHg, consider home non-invasive ventilation		*If daytime pCO<sub>2</sub> >52 mmHg, consider home non-invasive ventilation

	===Surgical Interventions===		===Surgical Interventions===

	====Lung ~~volume~~ ~~reduction~~ ~~surgery~~====		====Lung Volume Reduction Surgery====

	*Indicated if:		*Indicated if:
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	*Can decrease mortality in patients with heterogeneous, primarily upper-lobe emphysema		*Can decrease mortality in patients with heterogeneous, primarily upper-lobe emphysema

	====Lung ~~transplantation~~====		====Lung Transplantation====

	*Indicated if:		*Indicated if:

Aidan at 23:18, 30 July 2020

2020-07-30T23:18:05Z

Show changes

Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

2020-07-19T12:42:16Z

Text replacement - "Clinical Presentation" to "Clinical Manifestations"

← Older revision		Revision as of 12:42, 19 July 2020
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	* Biofuel use		* Biofuel use

	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	* Dyspnea, chronic cough or sputum production		* Dyspnea, chronic cough or sputum production

Maintenance script: Imported from text file

2020-07-04T01:17:28Z

Imported from text file

New page

== Definition ==

* Slowly progressive disease involving airways and lung parenchyma characterized by persistent airflow limitation

== Etiology ==

* Tobacco smoke is by far the most common cause
** Usually >10 pack-year history
* Biofuel smoke (wood, animal dung, coal, crop residues), organic or inorganic dust, chronic untreated asthma, air pollution

== Pathophysiology ==

== Differential Diagnosis ==

* Dyspnea
* Pulmonary disease
** Airways: asthma, bronchiectasis
** Parenchyma: ILDs
** Vessels: PH, PE
** etc
* Chronic ough
* etc

== Risk Factors ==

* Smoking
* Age
* Biofuel use

== Clinical Presentation ==

* Dyspnea, chronic cough or sputum production
* Match test (cannot blow out a lit match)

== Diagnosis ==

* Pulmonary function tests (PFTs)
** Post-bronchodilator FEV1/FVC ratio <0.7 for diagnosis
** Possibly elevated TLC (gas trapping) and low DLCO (suggests emphysema)

== Investigations ==

== GOLD Classification ==

* Class I (mild): FEV1 ≥80%
* Class II (moderate): FEV1 50-79%
* Class III (severe): FEV1 30-49%
* Class IV (very severe): FEV1 ≤29%

== Management ==

=== Acute ===

* See [[Acute exacerbation of COPD]]

=== Chronic ===

* Preventative/non-pharmacologic
** Smoking cessation (improves survival), education
** Flu shots, pneumococcal vaccination
** Pulmonary rehabilitation (improves survival if within 4 weeks of exacerbation)
* Step-wise puffers: note that no puffers improve survival
** Short-acting anticholinergic bronchodilators prn: ipratropium/salbutamol
** Long-acting anticholinergic bronchodilators: tiotropium
** Long-acting beta-agonist: salmeterol or formoterol
** Inhaled corticosteroid (ICS): decreases frequency of exacerbations, but increases risk of pneumonia
* Home oxygen
** Improves survival if:
*** Resting PaO2 < 55mmHg
*** Resting PaO2 < 60mmHg plus cor pulmonale
** Target SpO<s>2</s> >90%
** May not improve dyspnea
* If frequent exacerbations, consider roflumilast or azithromycin or NAC
* If daytime pCO<s>2</s> >52 mmHg, consider home non-invasive ventilation

=== Surgical Interventions ===

==== Lung volume reduction surgery ====

* Indicated if:
** Severe COPD
** Symptomatic despite maximal pharmacologic therapy
** Completed pulmonary rehabilitation
** Evidence of bilateral predominant upper-lobe emphysema on CT
** Postbronchodilator total lung capacity greater than 100% and residual lung volume greater than 150% of predicted
** Maximum FEV1 greater than 20% and less than or equal to 45% of predicted and DLCO greater than or equal to 20% of predicted
** Ambient air arterial PCO2 less than or equal to 60 mm Hg (8.0 kPa) and arterial PO2 greater than or equal to 45 mm Hg (6.0 kPa)
* Can decrease mortality in patients with heterogeneous, primarily upper-lobe emphysema

==== Lung transplantation ====

* Indicated if:
** Pulmonary hypertension, cor pulmonale, or both despite oxygen therapy
** History of exacerbation associated with acute hypercapnia
** FEV1 less than 20% of predicted with DLCO less than 20% of predicted or homogeneous distribution of emphysema
* Contraindications includes: active smoking or substance use, cancer within 2 years, organ dysfunction, incurable chronic infection, anatomical abnormalities, lack of social support, or untreated psychiatric disorder
* Improves quality of life

=== Symptomatic Management of Advanced COPD ===

* Can use oral opioids for dyspnea
* Walking aids and pursed-lip breathing
* Home oxygen if hypoxemic at rest, but may not affect quality of life
* Also: neuromuscular electrical muscule stimulation and chest wall vibration
* No role for anxiolytics or antidepressants

== Further Reading ==

* CTS guidelines
* TORCH trial: Jenkins CR, ''et al.'' [https://dx.doi.org/10.1186%2F1465-9921-10-59 Efficacy of salmeterol/fluticasone propionate by GOLD stage of chronic obstructive pulmonary disease: analysis from the randomised, placebo-controlled TORCH study]. ''Respir Res''. 2009;10(1):59.
** LABA+ICS decreased exacerbations and hospitalizations compared to either alone, but ICS increased pneumonia

[[Category:Respirology]]