CHAPTER-II

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

(COPD)

BY

J. jayasutha

lecturer

department of pharmacy pr actice

Srm college of pharmacy

SRM UNIVERSITY

COPD DEFINED BY AMERICAN THORACIC SOCIETY BY 1995 GUIDELINES

COPD as a disease state is characterized by chronic airflow limitation due to chronic bronchitis and emphysema.

Chronic bronchitis has been defined in clinical terms:the presence of chronic productive cough for at least 3 consecutive months in 2 consecutive years.

Emphysema, on the other hand, has been defined by its pathologic description:

an abnormal enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis.

GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD) UPDATED

2010 CRITERIA FOR COPD

A disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gasesAirflow limitation is the slowing of expiratory airflow as measured by spirometry, with a persistently low forced expiratory volume in 1 second (FEV1) and a low FEV1/forced vital capacity (FVC) ratio despite treatment.Airflow limitation is defined as an FEV1/FVC ratio of less than 70%.

AMERICAN THORACIC SOCIETY (ATS)/EUROPEAN RESPIRATORY SOCIETY (ERS)

UPDATED DEFINITION OF COPD

Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible.

The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.

CLASSIFICATION OF COPD

CHIEF COMPLAINT: SHORTNESS OF BREATHCOPD VS ASTHMA?

CHIEF COMPLAINT: SHORTNESS OF BREATHDIFFERENTIAL DIAGNOSIS

Exacerbations of COPD can be caused by many factors, including environmental irritants, heart failure or noncompliance with medication use

Most often, however, exacerbations are the result of bacterial or viral infection. Bacterial infection is a factor in 70 to 75 percent of exacerbations.

CAUSES OF COPD EXACERBATIONS

Oxygenation

Bronchodilators

Anticholingerics

Antibiotics

Corticosteroids

TREATMENT OPTIONS FOR COPD EXACERBATION

Initial therapy should focus on maintaining oxygen saturation at 90 percent or higher.

Oxygen supplementation by nasal cannula or face mask is frequently required.

With more severe exacerbations, intubation or a positive-pressure mask ventilation method (e.g., continuous positive airway pressure [CPAP]) is often necessary to provide adequate oxygenation.

OXYGENATION IN COPD EXACERBATION

Inhaled beta2 agonists should be administered as soon as possible during an acute exacerbation of COPD.

Albuterol (Ventolin) nebulizers from continuous to Q6hrs either standing or PRN depending on severity of exacerbation. Salmeterol (Serevent), a long-acting beta2 agonist, has been shown to relieve symptoms in patients with COPD. Twice-daily dosing is an added benefit and may be convenient for many patients.

BRONCHODILATORS IN COPD EXACERBATIONS

Compared with beta2 agonists, inhaled anticholinergics such as ipratropium (Atrovent) provide the same or greater bronchodilation.

Dosing: Ipratropium 500mcg/2.5ml Nebs from continuous to Q6hrs Standing or PRN depending on severity disease

Use of a combination product such as ipratropium-albuterol (Combivent, DuoNebs) may simplify the medication regimen, thereby improving compliance

ANTICHOLINGERICS IN COPD EXACERBATIONS

Mild to moderate exacerbationsStreptococcus pneumoniaeHaemophilus influenzaeMoraxella catarrhalisChlamydia pneumoniaeMycoplasma pneumoniaeViruses

Severe exacerbationsPseudomonas speciesOther gram-negative enteric bacilli

MOST COMMON INFECTIOUS CAUSES OF COPD EXACERBATIONS

Mild to moderate exacerbationsFirst-l ine antibiotics

Doxycycline (Vibramycin), 100 mg twice dailyTrimethoprim-sulfamethoxazole (Bactrim DS, Septra DS), one tablet twice dailyAmoxicillin-clavulanate potassium (Augmentin), one 500 mg/125 mg tablet three times daily or one 875 mg/125 mg tablet twice daily

Alternative antibioticsMacrolides

Clarithromycin (Biaxin), 500 mg twice dailyAzithromycin (Zithromax), 500 mg initially, then 250 mg daily

FluoroquinolonesLevofloxacin (Levaquin), 500 mg dailyGatifloxacin (Tequin), 400 mg dailyMoxifloxacin (Avelox), 400 mg daily

ANTIBIOTIC CHOICES FOR COPD EXACERBATIONS

Moderate to severe exacerbations: Recommend IV antibioticsCephalosporins

Ceftriaxone (Rocephin), 1 to 2 g IV dailyCefotaxime (Claforan), 1 g IV every 8 to 12 hoursCeftazidime (Fortaz), 1 to 2 g IV every 8 to 12 hours

Antipseudomonal penicill insPiperacillin-tazobactam (Zosyn), 3.375 g IV every 6 hoursTicarcillin-clavulanate potassium (Timentin), 3.1 g IV every 4 to 6 hours

FluoroquinolonesLevofloxacin, 500 mg IV dailyGatifloxacin, 400 mg IV daily

AminoglycosideTobramycin (Tobrex), 1 mg per kg IV every 8 to 12 hours, or 5 mg per kg IV daily

ANTIBIOTIC CHOICES FOR COPD EXACERBATIONS

For severe exacerbations of COPD requiring inpatient therapy, methylprednisolone sodium succinate is commonly used initially.

Dosage: Commonly 60mg or 125mg every six to twelve hours depending on severity of exacerbations

After two to three days of intravenous therapy, the patient can be switched to orally administered prednisone in a starting dosage of 60 mg daily for a total of two weeks of therapy.

CORTICOSTEROIDS IN COPD EXACERBATIONS

Treatment of the obstructionBronchodilators

Anticholinergics

Intravenous or oral corticosteroids

Intravenous or oral antibiotics

Assess for hyoxemiaConsider supplemental O2 is PaO2 < 55mgHg or nocturnal saturation is less than 88%

Consider positive pressure ventilation, CPAP or intubation, if necessary

Encourage nonpharmacologic interventionsSmoking cessation, patient education, nutrition, influenza and pneumococcal vaccines

SUMMARY TREATMENT OPTIONS

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