Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive life-threatening lung disease that initially presents as breathlessness with exertion, but if left untreated will develop into a serious illness. It is subdivided into chronic bronchitis and emphysema:

Chronic bronchitis

  • Phlegmy cough for at least 3 months annually for 2 consecutive years.

Emphysema

  • Lung tissue involved in the exchange of gases is impaired or destroyed. The damaged tissue closes the small airways of the lungs (bronchioles).

Smoking, air pollution and recurrent respiratory infections play a role in COPD causes. It is an extremely prevalent disease, being the fourth leading cause of death worldwide.([FOOTNOTE=World Health Organization. The top 10 causes of death. http://www.who.int/mediacentre/factsheets/fs310/en/],[ANCHOR=],[LINK=])

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Diagnosis

Patients with COPD typically present with a combination of symptoms of chronic bronchitis, emphysema, and reactive airway disease. Symptoms include the following([FOOTNOTE=Agusti A, Hurd S, Jones, P  et al. FAQs about the GOLD 2011 assessment proposal of COPD: a comparative analysis of four different cohorts. European Respiratory Journal 2013; 42: 1391-1401],[ANCHOR=],[LINK=]):

Coughing:

  • Usually worse in the mornings, which produces a small amount of colourless sputum

Breathlessness:

  • The most prevalent symptom, particularly in over 50s

Wheezing:

  • May occur in some patients, particularly during physical exertion

Diagnosis is primarily based on clinical presentation and lung function tests. Arterial blood gas tests and pulse oximetry are useful for quickly assessing the patient's O2 status. All COPD patients are diagnosed according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The GOLD system categorises airflow limitation in patients as follows:

The four Gold stages of COPD3

The four Gold stages of COPD([FOOTNOTE=Vestbo J, Hurd SS, Augusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-65.],[ANCHOR=],[LINK=])
Stage 1 - Mild
FEV1≥ 80% predicted
Stage 2 - Moderate 50% ≤FEV1 <80% predicted
Stage 3 - Severe 30% ≤FEV1 <50% predicted
Stage 4 - Very Severe Stage 4 - Very severe FEV1 <30% predicted

Symptoms

The ability to detect mild to moderate COPD through physical examination can be quite poor, but physical signs are more specific and pronounced for severe disease. Severe COPD may present itself through the following symptoms:([FOOTNOTE=Siafakas NM, Vermeire P, Pride P, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). Eur Respir. 1995;   8, 1398–1420],[ANCHOR=],[LINK=]),([FOOTNOTE=Garcia-Pachon E & Padilla-Navas I. Frequency of Hoover’s sign in stable patients with chronic obstructive pulmonary disease. J Clin Pract. 2006; 60 (5) 514–517],[ANCHOR=],[LINK=])

  • Tachypnoea and respiratory distress from minimal physical exertion
  • Use of accessory respiratory muscles and Hoover’s sign (inward movement of the rib cage during inhalation rather than outward)
  • Cyanosis
  • Elevated jugular venous pulse (JVP)
  • Peripheral oedema

Treatment

In severe cases, COPD patients require hospitalisation or an emergency visit. Symptoms of confusion, lethargy, respiratory muscle fatigue, worsening hypoxemia, respiratory acidosis (pH < 7.30) and concern of respiratory failure are cause for emergency care.([FOOTNOTE=American Thoracic Society. Inpatient Management of COPD. Am J Resp Crit Care Med. 1995; 152(5):97-106.],[ANCHOR=],[LINK=]) In such cases ventilatory support and intensive care unit (ICU) admission are frequent([FOOTNOTE=Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison DA, et al. Predicting mortality for patients with exacerbations of COPD and Asthma in the COPD and Asthma Outcome Study (CAOS) QJM. 2009;102(6):389–399.],[ANCHOR=],[LINK=]) , ([FOOTNOTE=Global Initiative for COPD. Global Strategy for Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. 2018 Report.],[ANCHOR=],[LINK=]),([FOOTNOTE=Nascimento OA, Camelier A, Rosa FW, et al; Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) Group. Chronic obstructive pulmonary disease is underdiagnosed and undertreated in São Paulo (Brazil): results of the PLATINO study. Braz J Med Biol Res. 2007;40(7):887–895.],[ANCHOR=],[LINK=]),([FOOTNOTE=Pincelli MP, Grumann AC, Fernandes C, et al. Characteristics of COPD patients admitted to the ICU of a referral hospital for respiratory diseases in Brazil. J Bras Pneumol. 2011;37(2):217–222.],[ANCHOR=],[LINK=]),([FOOTNOTE=Ai-Ping C, Lee KH, Lim TK. In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study. Chest. 2005;128(2):518–524.],[ANCHOR=],[LINK=],([FOOTNOTE=Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison DA, et al. Predicting mortality for patients with exacerbations of COPD and Asthma in the COPD and Asthma Outcome Study (CAOS) QJM. 2009;102(6):389–399.],[ANCHOR=],[LINK=]),([FOOTNOTE=McCauley P, Dutta D. Management of COPD patients in the intensive care unit. Crit Care Nurs Clin North Am. 2012;24(3):419-30.],[ANCHOR=],[LINK=]),([FOOTNOTE=Steer J, Gibson GJ, Bourke SC. Predicting outcomes following hospitalisation for acute exacerbations of COPD. QJM. 2010;103(11):817–829.],[ANCHOR=],[LINK=]),([FOOTNOTE=Davidson AC. Critical care management of respiratory failure resulting from COPD. Thorax. 2002;57:1079-1084.],[ANCHOR=],[LINK=]),([FOOTNOTE=Afessa B, Morales IJ, Scanlon PD, Peters SG. Prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure. Crit Care Med. 2002;30(7):1610–1615.],[ANCHOR=],[LINK=]),([FOOTNOTE=Seneff MG, Wagner DP, Wagner RP, et al. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA. 1995;274(23):1852–1857.],[ANCHOR=],[LINK=]) ,16

In-hospital management of COPD is mainly focused on the acute stage with demand-responsive measures, such as pharmacotherapy, oxygen therapy, noninvasive ventilation and invasive mechanical ventilation.

OXYGEN AND NONINVASIVE VENTILATION THERAPY FOR COPD

COPD can result in hypercapnia – elevated levels of carbon dioxide in the body – necessitating oxygen therapy. But oxygen treatment can bring its own set of risk factors, with hyperoxia – elevated levels of oxygen in the body – reported in some cases.([FOOTNOTE=Sassoon CH, Hassell KT, and Mahutte, CK. Hyperoxic-induced hypercarpnia in stable COPD. Am Rev Respir Dis. 1987; 135(4):907-11.],[ANCHOR=],[LINK=]) Hypercapnia can result in impaired cognitive function.([FOOTNOTE=Icalizi RA, Gemma A, Marra C, et al. 1993. Chronic obstructive pulmonary disease. An original model of cognitive decline. Am Rev Respir Dis. 1993;148(2):418-24.],[ANCHOR=],[LINK=]) In addition, hypercapnia has been associated with a poorer prognosis in patients with COPD([FOOTNOTE=Yang H, Xiang P, Zhang E, et al. Is hypercapnia associated with poor prognosis in chronic obstructive pulmonary disease? A long-term follow-up cohort study. BMJ Open. 2015; 15(12):e008909.],[ANCHOR=],[LINK=]), and both hypercapnia and hypoxia may result in deleterious effects on the lungs.([FOOTNOTE=Vadász I, Hubmayr RD, Nin N, et al.  Hypercapnia: a nonpermissive environment for the lung. Am J Respir Cell Mol Biol. 2012 Apr;46(4):417-21.],[ANCHOR=],[LINK=]),([FOOTNOTE=Mach WJ, Thimmesch AR, Pierce JT, et al.  Consequences of hyperoxia and the toxicity of oxygen in the lung. Nurs Res Pract. 2011:260482],[ANCHOR=],[LINK=])

Correctly administered, noninvasive ventilation (NIV) coupled with long term oxygen therapy (LTOT) is beneficial to COPD patients with hypercapnia. Furthermore, usage of NIV or noninvasive positive pressure ventilation (NPPV) can control oxygen toxicity in COPD patients with hypercapnia.([FOOTNOTE=Alhamed MK, Aljaziri FJM, Aljunaid MA, et al. Meta-Analysis - Prevention of Oxygen Toxicity in COPD Patients with Hypercapnia. EC Microbiology. 2017;10(2):37-46.],[ANCHOR=],[LINK=])

Oxygen should be prescribed to achieve a target saturation of 94–98% (a figure checked by pulse oximetry) for the most acutely ill patients, and lower, patient-specific target ranges for those less acutely at risk of hypercapnic respiratory failure.([FOOTNOTE=O'Driscoll BR, Howard LS, Earis J and Mak V on behalf of the BTS Emergency Oxygen Guideline Development Group. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Resp Res 2017;4:e000170.],[ANCHOR=],[LINK=])

 

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