​Kembara Xtra - Medicine - Chronic Obstructive Pulmonary Disease

​Kembara Xtra - Medicine - Chronic Obstructive Pulmonary Disease
Introduction 
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), COPD is "a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host factors, including abnormal lung development." Emphysema and chronic bronchitis are no longer included in this revised definition.
● 90% of COPD deaths occur in low- and middle-income nations, making it the third greatest cause of mortality globally. In 2019, COPD was the cause of 3.2 million fatalities worldwide.

Prevention Incidence
8.9 cases of COPD occur for every 1,000 person-years.

Pathophysiology and Etiology 
The following pathologic conditions in the lung are brought on by exposure to noxious gases or particles:
Impaired gas exchange (between carbon dioxide and oxygen)
Lung parenchyma destruction Ongoing airway obstruction

Genetics Host reaction to noxious gases or particles may be influenced by genetics.
Due to two autosomal codominant alleles, antiprotease deficiency (caused by 1 antitrypsin deficiency) is a hereditary, rare illness.

Risk factors include smoking marijuana or tobacco, as well as passive smoking and water pipes.
Asthma and airway hyperreactivity Indoor air pollution, especially indoor biomass cooking worldwide History of severe childhood respiratory infections Aging, including healthy aging as well as the cumulative sum of lung exposure over time Lower level of education and lower socioeconomic status 
DURATIONAL PREVENTION
The most crucial preventive measure is quitting smoking and avoiding toxic materials in general.

Accompanying Conditions 
Asthma, pulmonary hypertension (HTN), acute bronchitis, chronic respiratory failure, lung cancer, sleep apnea, and sleep apnea are cardiac conditions.

Chronic sinusitis and laryngeal cancer are ENT conditions. Other conditions include depression, starvation, osteoporosis, and muscle dysfunction.


Diagnosis 
Three characteristics are necessary for COPD diagnosis:
A ratio of 0.7 or below between the post-bronchodilator forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), which indicates a continuing airflow restriction.

 Appropriate symptoms such as wheezing, dyspnea, a persistent cough, and/or sputum production
 Significant exposure to unpleasant stimuli, such as a history of cigarette smoking or exposure to the environment


Introducing History 
Talk about the patient's use of marijuana or tobacco.
Take indoor pollution and occupational hazards into consideration.
Review potential exacerbation factors, such as cold weather, a recent upper respiratory infection, pneumonia, or medication noncompliance.
Exacerbation symptoms include increased sputum production, a change in sputum color, frequency, or volume, fevers, wheezing, and tightness or pain in the chest.

clinical assessment 
Wheezing for an extended period of time, barrel chest, reduced breath sounds, distant heart sounds, accessory muscle use, pursed lip breathing, cyanosis, and clubbing, which are not typical of COPD but may be signs of another condition (such as lung cancer).

Differential diagnosis includes: bronchiolitis obliterans, bronchiectasis, primary alveolar hypoventilation, reactive airways dysfunction syndrome (RADS), lung cancer, chronic pulmonary embolism, sleep apnea, congestive heart failure (CHF), gastroesophageal reflux disease, and cystic fibrosis.

Diagnostic tests and laboratory results 

Initial examinations (lab, imaging)
The spirometer 
ABGs (arterial blood gases) can reveal hypoxia and hypercapnia.
CBC results could show polycythemia, a sign of persistent hypoxia.
BMP may show increased CO2, a sign of long-term CO2 retention.
Imaging (CXR, CT chest) is crucial to rule out other disorders; on the CXR, there may be bullous changes, hyperinflation, and flat diaphragms.

Tests in the Future & Special Considerations
1-Antitrypsin screening for those with COPD age 45 years, have a blood relative with this illness, or have spirometry out of proportion to cigarette use Chest CT may show parenchymal damage and bullae. Pulse oximetry to determine need for oxygen, both at rest and with exertion.
Diagnostic Procedures/Other Bronchodilator-free/Bronchodilator-included pulmonary function assessment Decreased post-bronchodilator FEV1:FVC ratio 0.7. The following are the diagnostic standards for airway obstruction: Reduced FEV1; Normal or increased FVC; Normal or increased total lung capacity; Increased residual volume and functional residual capacity; Diffusing capacity is normal or reduced. Repeat spirometry is advised if the results are between 0.6 and 0.8.
Usually not sensitive to bronchodilators (change in FEV1 or FVC of 12% or less, and change in volume of 200 mL).

Interpretation of Tests
Stage: GOLD standard for airflow restriction (1)
FEV1 is projected to be 80% in grade one, 50–80% in grade two, and 30–50% in grade three.
- Grade 4: Chronic respiratory failure and FEV1 anticipated at or below 50%
- FEV1 was once used to classify severity, however it was later discovered to have poor correlations with patients' functional ability and risk for exacerbation.
Ratings of the severity of the symptoms:
- The COPD Assessment Tool (CAT), an 8-item questionnaire worth 5 points each (with a total score range of 0 to 40), which assesses the quality of life associated with the condition.
- The modified Medical Research Council (mMRC) questionnaire rates breathlessness on a scale of 0 (breathless with vigorous exercise) to 4 (too breathless to leave the house or breathless when dressing or undressing).
- GOLD severity evaluation based on symptom load and exacerbation risk
The ABCD assessment tool takes into account the severity of the patient's symptoms and their history of exacerbations.
- Group A: minimal risk, less symptoms, CAT score 10 or mMRC grade 0 to 1; 0 to 1 exacerbation per year; and no prior hospitalization for exacerbation.
- Group B: low risk, more symptoms: 0–1 exacerbations annually; no history of exacerbation-related hospitalizations; and CAT score of 10 or mMRC grade of 2.
- Group C: high risk, less symptoms: CAT score of 10 or mMRC grade 0 to 1, and 2 exacerbations each year or 1 hospitalization for exacerbation
- Group D: high risk, greater symptoms: two or fewer exacerbations year, one exacerbation hospitalization, and a CAT score of 10 or a mMRC grade of two.

Management 

The most crucial action to lower the risk of disease progression is quitting smoking.
Home oxygen should be started when the partial pressure of arterial oxygen (PaO2) is less than 55 mm Hg, pulse oximetry trends are higher than 88%, or when the PaO2 is between 55 and 60 mm Hg and there are signs of erythrocytosis or cor pulmonale.
NPPV may increase hospitalization-free survival in hypercapnic patients after a recent hospitalization, along with influenza and pneumococcal vaccinations, pulmonary rehabilitation, and other interventions.

The First Line of Medicine
Low risk of aggravation and minimal symptoms (category A):
A short-acting bronchodilator to be used as a rescue medication, first line
Albuterol and levalbuterol are short-acting beta-agonists. Ipratropium and oxitropium are short-acting muscarinic antagonists.
More symptomatic, low risk of exacerbation (category B) - First line: routine long-acting bronchodilator use in addition to when necessary short-acting bronchodilators.
Second line: Instead of using steroids, use a combination of long-acting muscarinic agonists (LABA) and long-acting muscarinic antagonists (LAMA) if symptoms cannot be controlled by a single long-acting medication.
LAMA: tiotropium, aclidinium, umeclidinium, glycopyrrolate - LABA: formoterol, arformoterol, salmeterol - LAMA: minimal symptoms, high risk of aggravation (category C) - First line: LAMA
First line: LAMA-LABA combo; second line: LABA and inhaled corticosteroid (ICS); third line: More symptomatic, increased risk of exacerbation (category D);
- Second line: If FEV1 is less than 50% and you have chronic bronchitis, you can also add triple therapy with LAMA-LABA, ICS therapy, and PD4 inhibitor (roflumilast). If a former smoker, chronic macrolide therapy is recommended; theophylline is not advised due to side effects.

Warning in the second line or precautions

Levalbuterol may be considered as an antagonist for sinus tachycardia and other arrhythmias. Anticholinergics have little systemic absorption when inhaled and may cause urine retention.
Corticosteroids: weight gain, diabetes, adrenal suppression, osteoporosis, infection (pneumonia); ICS: increased risk of pneumonia; oral candidiasis; Macrolides: prolonged treatment may result in bacterial resistance and hearing loss.

Arrhythmia, CNS side effects, nausea, and vomiting

Motives for the Referral 
severe exacerbation, frequent hospitalizations, quick progression, loss of weight, serious illness, or surgical evaluation

Furthermore Treated 

Program for patients with significant symptom load and exacerbation risk in the lungs
Acute COPD exacerbations can be treated with short-acting bronchodilators, perhaps brief courses of steroids and/or antibiotics (5–7 days), and mild to moderate bronchodilators. Inpatient admission is necessary for severe exacerbations (see below).

Lung reduction surgery, bronchoscopic lung reduction, surgical bullectomy, and lung transplantation are all surgical options.

Admission

Maintaining oxygenation, using short-acting inhaled -agonists and inhaled anticholinergic drugs, and using oral or IV corticosteroids prednisone (up to 1 mg/kg/day; typically 40 mg/day for 5 days) are all recommended for severe acute exacerbations. It may result in acute or acute on chronic respiratory failure requiring ICU admission and intubation. Prior to discharge: Assess proper inhaler use, prescribe proper maintenance inhalers, and ensure understanding; assess need for home oxygen. Antibiotics for moderate/severe exacerbations with increased sputum volume or sputum purulence; optimal antibiotic therapy has not been determined; noninvasive positive pressure ventilation if necessary.
ALERT
Have the patient define an advance directive if one doesn't already exist.

For patients with a high burden of symptoms and a high risk of exacerbations, a pulmonary rehabilitation program may taper or cease oral steroids as an outpatient.
patient observation
Following an exacerbation, follow-up should take place initially within a 4-week window and then again after 12 weeks, paying attention to symptoms, medication compliance, and the requirement for oxygen in the first 4 weeks. Spirometry should also be done again in 12 weeks.
DIET Referral for nutritional support recommended for individuals who are undernourished


Prognosis: When necessary, more oxygen has been demonstrated to increase survival (it may only be needed at night).

The prognosis is improved by quitting smoking.
Lung volume reduction surgery may be an option for people with severe upper lobe illness who have poor control or poor post-rehabilitation exercise capacity.
Patients who have very severe diseases that don't respond to any treatments may be candidates for lung transplants.
Estimates of death after 4 years for COPD patients with mild to moderate disease range from 28% to 62%.

Complications include inadequate nourishment, restless sleep, infections, and secondary polycythemia.
Pneumothorax, bullous lung disease, acute or chronic respiratory failure, arrhythmias, cor pulmonale, and pulmonary HTN.

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