OBSTRUCTIVE AIRWAY AND PULMONARY

DISEASE
TABLE OF CONTENTS
1. ASTHMA BRONCHIALE

- WHAT IS KNOWN ABOUT ASTHMA
- DIAGNOSING ASTMA
- CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL
- FOUR COMPONENT OF ASTHMA
- Develop P!"e#!$Do%!o& P&!#e&'("p
- I)e#!"*+ #) Re),%e E-po',&e !o R"'. F%!o&
- A''e'/T&e!/#) Mo#"!o& A'!(0
- M#1eE-%e&2!"o#
- SPECIAL CONSIDERATION IN MANAGING ASTHMA
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5

- WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5
- RISK FACTOR6 WHAT CAUSE COPD7
- DIAGNOSING COPD
- COMPONENT OF CARE6
A COPD MANAGEMENT PROGRAM
Co0po#e#! 16 A''e' #) Mo#"!o& )"'e'e
Co0po#e#! 36 Re),%e R"'. F%!o&'
Co0po#e#! 86 M#1e S!2le COPD
Patient Education
Pharmacologic Treatment
Non-Pharmacologic Treatment
Co0po#e#! 96 M#1e E-%e&2!"o#'
How to Asses the Severity of an Exacerbation
Home Management
Hosital Management
!
1. ASTHMA BRONCHIALE
WHAT IS KNOWN ABOUT ASTHMA
" Asthma is a %(&o#"% "#*l00!o&+ )"'o&)e& of the airways# $hronically inflamed airways are
(+pe&&e'po#'"ve: they become obstructed and airflow is limited %by bronchoconstriction& mucus
lugs& and increased inflammation' when airways are exosed to various ris( factors#
. )efinition * Asthma is a chronic inflammatory disorder of the airways in wich many cells and
cellular elements lay a role %infiltration of mast cell&eosinofil and lymhocyte'# $hronic
inflammation causes an associated increase in airway hyerresonsiveness that leads to recurrent
eisodes of whee+ing& brethlessness,shorthness of breath& chest tighness& and coughing& symtom
varying overtime and severity articularly at night or in the early morning# These eisodes are
usually associated with widesread but variable airflow obstruction that is often reversible either
sontaneously or with treatment#
" $ommon &"'. *%!o&' for asthma symtoms include exosure to allergens %such as those from
house dust mites& animals with fur& coc(roaches& ollens& and molds'& occuational irritants& tobacco
smo(e& resiratory %viral' infections& exercise& strong emotional exressions& chemical irritants& and
drugs %such as asirin and beta bloc(ers'#
" A '!ep;"'e pp&o%( to harmacologic treatment to achieve and maintain control of asthma should
ta(e into account the safety of treatment& otential for adverse effects& and the cost of treatment
re-uired to achieve control#
" Asthma !!%.' %or exacerbations' are eisodic& but airway inflammation is chronically resent# .or
many atients& %o#!&olle& medication must be ta(en daily to revent symtoms& imrove lung
function& and revent attac(s# Rel"eve& medications may occasionally be re-uired to treat acute
symtoms such as whee+ing& chest tightness& and cough#
" To reach and maintain asthma control re-uires the develoment of a p&!#e&'("p between the
erson with asthma and his or her health care team#
DIAGNOSING ASTHMA

Asthma can often be diagnosed on the basis of a atient/s '+0p!o0' and
0e)"%l ("'!o&+ %F"1,&e 1'#
0
Measurements of l,#1 *,#%!"o# rovide an assessment of the severity& reversibility& and
variability of airflow limitation& and hel confirm the diagnosis of asthma#
Sp"&o0e!&+ is the referred method of measuring airflow limitation and its reversibility to
establish a diagnosis of asthma#
" An increase in .E1! of 2 !03 %or 2 044 ml' after administration of a bronchodilator
indicates reversible airflow limitation consistent with asthma# %However& most asthma
atients will not exhibit reversibility at each assessment& and reeated testing is dvised#'
Pe. e-p"&!o&+ *lo; 4PEF5 measurements can be an imortant aid in both diagnosis and
monitoring of asthma#
" PE. measurements are ideally comared to the atient/s own revious
best measurements using his,her own ea( flow meter#
" An imrovement of 54 6,min %or 2 043 of the re-bronchodilator PE.'
after inhalation of a bronchodilator& or diurnal variation in PE. of more
than 043 %with twice-daily readings& more than !43'& suggests a diagnosis of asthma#
Additional diagnostic tests*
" .or atients with symtoms consistent with asthma& but normal lung function&
measurements of "&;+ &e'po#'"ve#e'' to methacholine& histamine& mannitol& or exercise
challenge may hel establish a diagnosis of asthma#
" S."# !e'!' ;"!( lle&1e#' o& 0e',&e0e#! o* 'pe%"*"% I1E "# 'e&,06 The resence of
allergies increases the robability of a diagnosis of asthma& and can hel to identify ris(
factors that cause asthma symtoms in individual atients#
CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL
Traditionally& the degree of symtoms& airflow limitation& and lung function variability have
allowed asthma to be classified by 'eve&"!+ %e#g#& as7ntermittent& Mild Persistent& Moderate
Persistent& or Severe Persistent'#Ho;eve&/ it is imortant to recogni+e that asthma severity
involves both the severity of the underlying disease and its resonsiveness to treatment# 7n
addition& severity is not an unvarying feature of an individual atient/s asthma& but may
change over months or years#
Therefore& for ongoing management of asthma& %l''"*"%!"o# o* '!(0
2+ level o* %o#!&ol is more relevant and useful %F"1,&e 3'#
8
FOUR COMPONENTS OF ASTHMA CARE
The 1ol o* '!(0 %&e "' !o %("eve #) 0"#!"# %o#!&ol of the clinical manifestations
of the disease for rolonged eriods# 9hen asthma is controlled& atients can revent most
attac(s& avoid troublesome symtoms day and night& and (ee hysically active#
To reach this goal& four interrelated comonents of theray are re-uired*
Co0po#e#! 1. )evelo atient,doctor artnershi
Co0po#e#! 3. 7dentify and reduce exosure to ris( factors
Co0po#e#! 8. Assess& treat& and monitor asthma
Co0po#e#! 9. Manage asthma exacerbations
Co0po#e#! 16 Develop P!"e#!$Do%!o& P&!#e&'("p
The effective management of asthma re-uires the develoment of a artnershi between the
erson with asthma and his or her health care team#
9ith your hel& and the hel of others on the health care team& atients
can learn to*
" Avoid ris( factors
" Ta(e medications correctly
" :nderstand the difference between ;controller< and ;reliever< medications
" Monitor their status using symtoms and& if relevant& PE.
" =ecogni+e signs that asthma is worsening and ta(e action
" See( medical hel as aroriate
Education should be an integral art of all interactions between health care rofessionals and
atients# :sing a variety of methods>such as discussions %with a hysician& nurse& outreach
wor(er& counselor& or educator'& demonstrations& written materials& grou classes& video or
audio taes& dramas& and atient suort grous>hels reinforce educational messages#
Co0po#e#! 36 I)e#!"*+ #) Re),%e E-po',&e !o R"'. F%!o&'
To imrove control of asthma and reduce medication needs& atients should ta(e stes to
avoid the ris( factors that cause their asthma symtoms %F"1,&e 9'# However& many asthma
atients react to multile factors that are ubi-uitous in the environment& and avoiding some
of these factors comletely is nearly imossible# Thus& medications to maintain asthma
control have an imortant role because atients are often less sensitive to these ris( factors
when their asthma is under control#
Physical activity is a common cause of asthma symtoms but atients '(o,l) #o! vo")
e-e&%"'e. Symtoms can be revented by ta(ing a raid-acting inhaled ?0-agonist before
strenuous exercise %a leu(otriene modifier or cromone are alternatives'#
Patients with moderate to severe asthma should be advised to receive an "#*l,e#<
v%%"#!"o# every year& or at least when vaccination of the general oulation is advised#
7nactivated influen+a vaccines are safe for adults and children over age 8#
@
Co0po#e#! 86 A''e''/ T&e!/ #) Mo#"!o& A'!(0
A''e''"#1 A'!(0 Co#!&ol
Each atient should be assessed to establish his or her current treatment regimen& adherence to the
current regimen& and level of asthma control# A simlified scheme for recogni+ing controlled& artly
controlled& and uncontrolled asthma is rovided in F"1,&e 3#
T&e!"#1 !o A%("eve Co#!&ol
Each atient is assigned to one of five treatment ;stes#< F"1,&e = details the treatments at
each ste for adults and children age A and over# At each treatment ste& &el"eve& 0e)"%!"o#
should be rovided for -uic( relief of symtoms as needed# %However& be aware of how
much reliever medication the atient is using>regular or increased use indicates that asthma
is not well controlled#'
At Stes 0 through A& atients also re-uire one or more regular %o#!&olle& 0e)"%!"o#'/
which (ee symtoms and attac(s from starting# 7nhaled glucocorticosteroids %F"1,&e >' are
the most effective controller medications currently available#
.or most atients newly diagnosed with asthma or not yet on medication& treatment should
be started at Ste 0 %or if the atient is very symtomatic& at Ste 8'# 7f asthma is not
controlled on the current treatment regimen& treatment should be steed u until control is
achieved#
I#(le) 0e)"%!"o#' are referred because they deliver drugs directly to the airways where
they are needed& resulting in otent theraeutic effects with fewer systemic side effects#
7nhaled medications for asthma are available as ressuri+ed metered-dose inhalers %M)7s'&
breath-actuated M)7s& dry owder inhalers %)P7s'& and nebuli+ers# Sacer %or valved
holding-chamber' devices ma(e inhalers easier to use and reduce systemic absortion and
side effects of inhaled glucocorticosteroids#
Teach atients %and arents' how to use inhaler devices# )ifferent devices need different
inhalation techni-ues#
" Bive demonstrations and illustrated instructions#
" As( atients to show their techni-ue at every visit#
#
A
5
C
Mo#"!o&"#1 !o M"#!"# Co#!&ol
Dngoing monitoring is essential to maintain control and establish the lowest ste and dose of
treatment to minimi+e cost and maximi+e safety
AdEusting medication*
" 7f asthma is #o! %o#!&olle) on the current treatment regimen& '!ep ,p treatment# Benerally&
imrovement should be seen within ! month#
Fut first review the atient/s medication techni-ue& comliance& and avoidance of ris(
factors#
" 7f asthma is p&!l+ %o#!&olle)/ %o#'")e& '!epp"#1 ,p treatment& deending on whether
more effective otions are available& safety and cost of ossible treatment otions& and the
atient/s satisfaction with the level of control achieved#
" 7f %o#!&ol "' 0"#!"#e) for at least 8 months& '!ep )o;# with a gradual& stewise
reduction in treatment# The goal is to decrease treatment to the least medication necessary to
maintain control#
Monitoring is still necessary even after control is achieved& as asthma is a variable diseaseG
treatment has to be adEusted eriodically in resonse to loss of control as indicated by
worsening symtoms or the develoment of
an exacerbation#
Co0po#e#! 96 M#1e E-%e&2!"o#'
Exacerbations of asthma %asthma attac(s' are eisodes of a rogressive increase in shortness
of breath& cough& whee+ing& or chest tightness& or a combination of these symtoms#
Do #o! ,#)e&e'!"0!e !(e 'eve&"!+ o* # !!%.: severe asthma attac(s may be life
threatening# Their treatment re-uires close suervision
Mild attac(s& defined by a reduction in ea( flow of less than 043& nocturnal awa(ening&
and increased use of raid-acting ?0-agonists& can usually be treated at home if the atient is
reared and has a ersonal asthma management lan that includes action stes# Moderate
attac(s may re-uire& and severe attac(s usually re-uire& care in a clinic or hosital#
Asthma attac(s re-uire p&o0p! !&e!0e#!6
" 7nhaled raid-acting ?0-agonists in ade-uate doses are essential# %Fegin with 0 to @ uffs
every 04 minutes for the first hourG then mild exacerbations will re-uire 0 to @ uffs every 8
to @ hours& and moderate exacerbations 5 to !4 uffs every ! to 0 hours#'
" Dral glucocorticosteroids %4#A to ! mg of rednisolone,(g or e-uivalent during a 0@-hour
eriod' introduced early in the course of a moderate or severe attac( hel to reverse the
inflammation and seed recovery#
" Dxygen is given at health centers or hositals if the atient is hyoxemic %achieve D0
saturation of HA3'#
" $ombination ?0-agonist,anticholinergic theray is associated with lower hositali+ation
rates and greater imrovement in PE. and .E1!#
" Methylxanthines are not recommended if used in addition to high doses of inhaled ?0-
agonists# However& theohylline can be used if inhaled ?0-agonists are not available# 7f the
atient is already ta(ing theohylline on a daily basis& serum concentration should be
measured before adding short-acting theohylline#
Theraies #o! &e%o00e#)e) for treating asthma attac(s include*
" Sedatives %strictly avoid'
" Mucolytic drugs %may worsen cough'
" $hest hysical theray,hysiotheray %may increase atient discomfort'
" Hydration with large volumes of fluid for adults and older children %may be necessary for
younger children and infants'
I
" Antibiotics %do not treat attac(s but are indicated for atients who also have neumonia or
bacterial infection such as sinusitis'
" Einehrine,adrenaline %may be indicated for acute treatment of anahylaxis and
angioedema but is not indicated for asthma attac(s'
Mo#"!o& &e'po#'e !o !&e!0e#!6
Evaluate symtoms and& as much as ossible& ea( flow# 7n the hosital& also assess oxygen
saturationG consider arterial blood gas measurement in atients with susected
hyoventilation& exhaustion& severe distress& or ea( flow 84-A4 ercent redicted#
Follo; ,p6
After the exacerbation is resolved& the factors that reciitated the exacerbation should be
identified and strategies for their future avoidance imlemented& and the atient/s medication
lan reviewed#
SPECIAL CONSIDERATIONS IN MANAGING ASTHMA
Secial considerations are re-uired in managing asthma in relation to*
P&e1##%+. )uring regnancy the severity of asthma often changes& and atients may re-uire close
follow-u and adEustment of medications# Pregnant atients with asthma should be advised that the
greater ris( to their baby lies with oorly controlled asthma& and the safety of most modern asthma
treatments should be stressed# Acute exacerbations should be treated aggressively to avoid fetal
hyoxia#
? S,&1e&+. Airway hyerresonsiveness& airflow limitation& and mucus hyersecretion
redisose atients with asthma to intraoerative and ostoerative resiratory comlications&
articularly with thoracic and uer abdominal surgeries# 6ung function should be evaluated several
days rior to surgery& and a brief course of glucocorticosteroids rescribed if .E1! is less than I43
of the atient/s ersonal best#
? R("#"!"'/ S"#,'"!"'/ #) N'l Pol+p'. =hinitis and asthma often coexist in the same atient& and
treatment of rhinitis may imrove asthma symtoms# Foth acute and chronic sinusitis can worsen
asthma& and should be treated# Nasal olys are associated with asthma and rhinitis& often with
asirin sensitivity and most fre-uently in adult atients# They are normally -uite resonsive to toical
glucocorticosteroids#
? O%%,p!"o#l '!(0. Pharmacologic theray for occuational asthma is identical to theray for
other forms of asthma& but is not a substitute for ade-uate avoidance of the relevant exosure#
$onsultation with a secialist in asthma management or occuational medicine is advisable#
? Re'p"&!o&+ "#*e%!"o#'. =esiratory infections rovo(e whee+ing and increased
asthma symtoms in many atients# Treatment of an infectious exacerbation follows the same
rinciles as treatment of other exacerbations#
? G'!&oe'op(1el &e*l,-. Bastroesohageal reflux is nearly three times as revalent in atients
with asthma comared to the general oulation# Medical management should be given for the relief
of reflux symtoms& although this does not consistently imrove asthma control#
? A'p"&"#-"#),%e) '!(0. : to 0I ercent of adults with asthma& but rarely children& suffer from
asthma exacerbations in resonse to asirin and other nonsteroidal anti-inflammatory drugs# The
diagnosis can only be confirmed by asirin challenge& which must be conducted in a facility with
cardioulmonary resuscitation caabilities# $omlete avoidance of the drugs that cause symtoms is
the standard management#
? A#p(+l-"'. Anahylaxis is a otentially life-threatening condition that can both mimic and
comlicate severe asthma# Promt treatment is crucial and includes oxygen& intramuscular
einehrine& inEectable antihistamine& intravenous hydrocortisone& and intravenous fluid
H
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5
WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5
)efinition* $hronic Dbstructive Pulmonary )isease %$DP)' is a reventable and treatable
disease with some significant extraulmonary effects that may contribute to the severity in
individual atients# 7ts ulmonary comonent is characteri+ed by airflow limitation that is
not fully reversible# The airflow limitation is usually rogressive and associated with an
abnormal inflammatory resonse of the lung to noxious articles or gases# This definition
does not use the terms chronic bronchitis and emhysemaJ and excludes asthma %reversible
airflow limitation'#
Symtoms of $DP) include*
" $ough
" Sutum roduction
" )ysnea on exertion
Eisodes of acute worsening of these symtoms often occur#
*Chronic bronchitis& defined as the resence of cough and sutum roduction for at least 8
months in each of 0 consecutive years& is not necessarily associated with airflow limitation#
Emphysema& defined as destruction of the alveoli& is a athological term that is sometimes
%incorrectly' used clinically and describes only one of several structural abnormalities
resent in atients with $DP)#
RISK FACTORS6 WHAT CAUSES COPD7
Wo&l);")e/ %"1&e!!e '0o."#1 "' !(e 0o'! %o00o#l+ e#%o,#!e&e) &"'. *%!o& *o& COPD.
The genetic ris( factor that is best documented is a severe hereditary deficiency of alha-!
antitrysin# 7t rovides a model for how other genetic ris( factors are thought to contribute to $DP)#
$DP) ris( is related to the total burden of inhaled articles a erson encounters over their lifetime*
" To2%%o '0o.e& including cigarette& ie& cigar& and other tyes of tobacco smo(ing oular in
many countries& as well as environmental tobacco smo(e %ETS'
" O%%,p!"o#l ),'!' #) %(e0"%l' %vaors& irritants& and fumes' when the exosures are
sufficiently intense or rolonged " I#)oo& "& poll,!"o# from biomass fuel used for coo(ing and
heating in oorly vented dwellings& a ris( factor that articularly affects women in develoing
countries
" O,!)oo& "& poll,!"o# also contributes to the lungs/ total burden of inhaled articles& although it
aears to have a relatively small effect in causing $DP)# 7n addition& any factor that affects lung
growth during gestation and childhood %low birth weight& resiratory infections& etc#' has the
otential for increasing an individual/s ris( of develoing $DP)#
!4
DIAGNOSING COPD
A diagnosis of $DP) should be considered in any atient who has dysnea& chronic cough or sutum
roduction& and,or a history of exosure to ris( factors for the disease& esecially cigarette smo(ing
%F"1,&e 1'#
J9here sirometry is unavailable& the diagnosis of $DP) should be made using all available tools#
$linical symtoms and signs %abnormal shortness of breath and increased forced exiratory time' can
be used to hel with the diagnosis# A low ea( flow is consistent with $DP) but has oor secificity
since it can be caused by other lung diseases and by oor erformance# 7n the interest of imroving
the accuracy of a diagnosis of $DP)& every effort should be made to rovide access to standardi+ed
sirometry#
Spirometry is as important for the diagnosis of COPD as bloodpressure measurements are for the
diagnosis of hypertension. Spirometry should be available to all health care professionals.
Sirometry measurements used for diagnosis of $DP) include %see .igure 0& age H'*
" FVC %forced vital caacity'* maximum volume of air that can be exhaled during a forced maneuver#
" FEV! %forced exired volume in one second'* volume exired in the first second of maximal
exiration after a maximal insiration#
This is a measure of how -uic(ly the lungs can be emtied#
" FEV!$FVC6 .E1! exressed as a ercentage of the .1$& gives a clinically useful index of airflow
limitation#
The ratio .E1!,.1$ is between C43 and I43 in normal adultsG a value less than C43 indicates
airflow limitation and the ossibility of $DP)# .E1! is influenced by the age& sex& height and
ethnicity& and is best considered as a ercentage of the redicted normal value# There is a vast
literature on normal valuesG those aroriate for local oulations should be used
9hen erforming sirometry& measure*
" Forced Vital Caacity %FVC' and
" Forced Exiratory Volume in one second %FEV1'#
$alculate the .E1!,.1$ ratio#
!!
Sirometric results are exressed as ? P&e)"%!e) using aroriate normal values for the
erson/s sex& age& and height#
P!"e#!' ;"!( COPD !+p"%ll+ '(o; )e%&e'e "# 2o!( FEV1 #) FEV1$FVC. T(e
)e1&ee o* 'p"&o0e!&"% 2#o&0l"!+ 1e#e&ll+ &e*le%!' !(e 'eve&"!+ o* COPD. Ho;eve&/
2o!( '+0p!o0' #) 'p"&o0e!&+ '(o,l) 2e %o#'")e&e) ;(e# )evelop"#1 #
"#)"v"),l"<e) 0#1e0e#! '!&!e1+ *o& e%( p!"e#!.
S!1e' o* COPD
Stage I: Mild COPD - Mild airflow limitation %.E1!,.1$ K C43G .E1! 2LI43 redicted'
and sometimes& but not always& chronic cough and sutum roduction#
" At this stage& the individual may not be aware that his or her lung function is abnormal#
Stage II: Moderate COPD - 9orsening airflow limitation %.E1!,.1$ K C43G A43 ML .E1!
K I43 redicted'& with shortness of breath tyically develoing on exertion#
" This is the stage at which atients tyically see( medical attention because of chronic
resiratory symtoms or an exacerbation of their disease#
Stage III: Severe COPD - .urther worsening of airflow limitation %.E1!,.1$ K C43G 843
ML .E1! K A43 redicted'& greater shortness of breath& reduced exercise caacity& and
reeated exacerbations which have an imact on atients/ -uality of life#
Stage IV: Very Severe COPD - Severe airflow limitation %.E1!,.1$ K C43G .E1! K 843
redicted' or .E1! K A43 redicted lus chronic resiratory failure# Patients may have 1ery
Severe %Stage 71' $DP) even if the .E1! is N 843 redicted& whenever this comlication
is resent#
" At this stage& -uality of life is very areciably imaired and exacerbations may be life-
threatening#
!0
D"**e&e#!"l D"1#o'"'6 A maEor differential diagnosis is asthma# 7n some atients with chronic
asthma& a clear distinction from $DP) is not ossible using current imaging and hysiological
testing techni-ues# 7n these atients& current management is similar to that of asthma# Dther otential
diagnoses are usually easier to distinguish from $DP) %F"1,&e 8'#
COMPONENTS OF CARE6 A COPD MANAGEMENT PROGRAM
The goals of $DP) management include*
" =elieve symtoms
" Prevent disease rogression
" 7mrove exercise tolerance
" 7mrove health status
" Prevent and treat comlications
" Prevent and treat exacerbations
" =educe mortality
" Prevent or minimi+e side effects from treatment#
$essation of cigarette smo(ing should be included as a goal throughout the management rogram#
!8
THESE GOALS CAN BE ACHIEVED THROUGH IMPLEMENTATION OF A
COPD MANAGEMENT PROGRAM WITH FOUR COMPONENTS6
1. A''e'' #) Mo#"!o& D"'e'e
3. Re),%e R"'. F%!o&'
8. M#1e S!2le COPD
9. M#1e E-%e&2!"o#'
Co0po#e#! 16 A''e'' #) Mo#"!o& D"'e'e
A )e!"le) 0e)"%l ("'!o&+ of a new atient (nown or thought to have $DP) should assess*
@ Exosure to ris( factors& including intensity and duration#
@ Past medical history& including asthma& allergy& sinusitis or nasal olys& resiratory
infections in childhood& and other resiratory diseases
@ .amily history of $DP) or other chronic resiratory disease#
@ Pattern of symtom develoment#
@ History of exacerbations or revious hositali+ations for resiratory disorder#
@ Presence of comorbidities& such as heart disease& malignancies& osteoorosis& and
musculos(eletal disorders& which may also contribute to restriction of activity#
@ Aroriateness of current medical treatments#
@ 7mact of disease on atient/s life& including limitation of activityG missed wor( and
economic imactG effect on family routinesG and feelings of deression or anxiety#
@ Social and family suort available to the atient#
@ Possibilities for reducing ris( factors& esecially smo(ing cessation#
7n addition to 'p"&o0e!&+& the following o!(e& !e'!' should be underta(en for the assessment
of a atient with Moderate (Stage !" Severe(Stage !" and #ery Severe (Stage #! COPD#
@ B&o#%(o)"l!o& &eve&'"2"l"!+ !e'!"#16 To rule out a diagnosis of asthma& articularly in
atients with an atyical history %e#g#& asthma in childhood and regular night wa(ing with
cough and whee+e'#
@ C(e'! A-&+6 Seldom diagnostic in $DP) but valuable to exclude alternative diagnoses
such as ulmonary tuberculosis& and identify comorbidities such as cardiac failure#
@ A&!e&"l 2loo) 1' 0e',&e0e#!6 Perform in atients with .E1! K A43 redicted or with
clinical signs suggestive of resiratory failure or right heart failure# The maEor clinical sign
of resiratory failure is cyanosis# $linical signs of right heart failure include an(le edema
and an increase in the Eugular venous ressure# =esiratory failure is indicated by PaD0 K I#4
(Pa %54 mm Hg'& with or without Pa$D0 N 5#C (Pa %A4 mm Hg' while breathing air at sea
level#
@ Alp(-1 #!"!&+p'"# )e*"%"e#%+ '%&ee#"#16 Perform when $DP) develos in atients of
$aucasian descent under @A years or with a strong family history of $DP)#
!@
Co0po#e#! 36 Re),%e R"'. F%!o&'
Smoking cessation: is the single most effective>and costeffective>intervention to reduce
the ris( of develoing$DP) and slow its rogression#
Smoking Prevention: Encourage comrehensive tobacco-control olicies and rograms with
clear& consistent& and reeated nonsmo(ing messages# 9or( with government officials to
ass legislation to establish smo(e-free schools& ublic facilities& and wor( environments and
encourage atients to (ee smo(e-free homes#
Occupational Exposures: Emhasi+e rimary revention& which is best achieved by
elimination or reduction of exosures to various substances in the wor(lace# Secondary
revention& achieved through surveillance and early detection& is also imortant#
Indoor and Outdoor ir Pollution: 7mlement measures to reduce
or avoid indoor air ollution from biomass fuel& burned for coo(ing and heating in oorly
ventilated dwellings# Advise atients to monitor ublic announcements of air -uality and&
deending on the severity of their disease& avoid vigorous exercise outdoors or stay indoors
altogether during ollution eisodes#
Co0po#e#! 86 M#1e S!2le COPD M#1e0e#! o* '!2le COPD '(o,l) 2e 1,")e)
2+ !(e *ollo;"#1 1e#e&l p&"#%"ple'6
P!"e#! e),%!"o# can hel imrove s(ills& ability to coe with illness& and health status# 7t is
an effective way to accomlish smo(ing cessation& initiate discussions and understanding of
advance directives and end-oflife issues& and imrove resonses to acute exacerbations#
P(&0%olo1"% !&e!0e#! %F"1,&e =' can control and revent symtoms& reduce the
fre-uency and severity of exacerbations& imrove health status& and imrove exercise
tolerance#
!ronc"odilators: These medications are central to symtom management in $DP)#
" 7nhaled theray is referred#
" Bive ;as needed< to relieve intermittent or worsening symtoms& and on a regular basis to
revent or reduce ersistent symtoms#
" The choice between ?0-agonists& anticholinergics& methylxanthines& and combination
theray deends on the availability of medications and each atient/s individual resonse in
terms of both symtom relief and side effects#
" =egular treatment with long-acting bronchodilators is more effective and convenient than
treatment with short-acting bronchodilators#
" $ombining bronchodilators may imrove efficacy and decrease the ris( of side effects
comared to increasing the dose of a single bronchodilator#
#lucocorticosteroids: =egular treatment with inhaled glucocorticosteroids is only
aroriate for atients with an .E1! K A43 redicted and reeated exacerbations %for
examle& 8 in the last three years'# This treatment has been shown to reduce the fre-uency of
exacerbations and thus imrove health status& but does not modify the long-term decline in
.E1!# The dose-resonse relationshis and long-term safety of inhaled
glucocorticosteroids in $DP) are not (nown# 6ong-term treatment with
oral glucocorticosteroids is not recommended#
Vaccines: nfluen$a vaccines reduce serious ilness and death in $DP) atients by A43#
1accines containing (illed or live& inactivated viruses are recommended& and should be
given once each year# Pneumococcal polysaccharide vaccine is recommended for $DP)
atients 5A years and older& and has been shown to reduce community-ac-uired neumonia
in those under age 5A with .E1! K @43 redicted#
nti$iotics6 Not recommended excet for treatment of infectious exacerbations and other
bacterial infections#
!A
Mucolytic %Mucokinetic& Mucoregulator' gents: Patients with viscous sutum may benefit
from mucolytics& but overall benefits are very small# :se is not recommended#
ntitussives: =egular use contraindicated in stable $DP)#

No#-P(&0%olo1"% T&e!0e#! includes rehabilitation& oxygen theray& and surgical
interventions#
(e"a$ilitation rograms should include& at a minimum*
" Exercise training
" Nutrition counseling
" Education
Patients at all stages of disease benefit from exercise training rograms& with imrovements
in exercise tolerance and symtoms of dysnea and fatigue# Fenefits can be sustained even
after a single ulmonary rehabilitation rogram# The minimum length of an effective
rehabilitation rogram is 5 wee(sG the longer the rogram continues& the more effective the
results# Fenefit does wane after a rehabilitation rogram
ends& but if exercise training is maintained at home the atientOs health status remains above
re-rehabilitation levels#
Oxygen )"erapy: The long-term administration of oxygen %N!A hours er day' to atients
with chronic resiratory failure increases survival and has a beneficial imact on ulmonary
hemodynamics& hematologic characteristics& exercise caacity& lung mechanics& and mental
state#
7nitiate oxygen theray for atients with Stage #% #ery Severe COPD if*
" PaD0 is at or below C#8 (Pa %AA mm Hg' or SaD0 is at or below II3& with or without
hyercaniaG or
" PD0 is between C#8 (Pa %AA mm Hg' and I#4 (Pa %54 mm Hg' or SaD0 is II3& if there is
evidence of ulmonary hyertension& eriheral edema suggesting congestive heart failure&
or olycythemia %hematocrit N AA3'#
Surgical )reatments: Fullectomy and lung translantation may be considered in carefully
selected atients with Stage #% #ery SevereCOPD# There is currently no sufficient evidence
that would suort the widesread use of lung volume reduction surgery %61=S'#
)"ere is no convincing evidence t"at mec"anical ventilatory
support "as a role in t"e routine management o* sta$le COPO
!5
A summary of characteristics and recommended treatment at each stage
of $DP) is shown in F"1,&e >#
Co0po#e#! 96 M#1e E-%e&2!"o#'
An exacerbation of $DP) is defined as an event in t"e naturalcourse o* t"e disease c"aracteri+ed
$y a c"ange in t"e patient,s $aseline dyspnea& coug"& and-or sputum t"at is $eyond normal day-to-
day variations& is acute in onset&and may .arrant a c"ange in regular medication in a patient .it"
underlying COPD/
The most common causes of an exacerbation are infection of the tracheobronchial tree and air
ollution& but the cause of about one-third of severe exacerbations cannot be identified#
Ho; !o A''e'' !(e Seve&"!+ o* # E-%e&2!"o#
&rterial blood gas measurements (in hospital!%
" PaD0 K I#4 (Pa %54 mm Hg' and,or SaD0 K H43 with or without Pa$D0 N 5#C (Pa& %A4 mmHg'
when breathing room air indicates resiratory failure#
" Moderate-to-severe acidosis %H K C#85' lus hyercania %Pa$D0 N 5-I (Pa& @A-54 mm Hg' in a
atient with resiratory failure is an indication for mechanical ventilation#
Chest '(ray% $hest radiograhs %osterior,anterior lus lateral' identify alternative diagnoses that can
mimic the symtoms of an exacerbation#
EC)% Aids in the diagnosis of right ventricular hyertrohy& arrhythmias& and ischemic eisodes#
!C
Other laboratory tests%
" Sutum culture and antibiogram to identify infection if there is no resonse to initial
antibiotic treatment# " Fiochemical tests to detect electrolyte disturbances& diabetes&
and oor nutrition#
" 9hole blood count can identify olycythemia or bleeding#
Ho0e M#1e0e#!
!ronc"odilators: 7ncrease dose and,or fre-uency of existing shortacting bronchodilator
theray& referably with ?0-agonists# 7f not already used& add anticholinergics until
symtoms imrove#
#lucocorticosteroids: 7f baseline .E1! K A43 redicted& add 84-@4 mg oral rednisolone
er day for C-!4 days to the bronchodilator regimen# Nebuli+ed budesonide may be an
alternative to oral glucocorticosteroids in the treatment of nonacidotic exacerbations#
Ho'p"!l M#1e0e#!
Patients with the characteristics listed in F"1,&e B should be hositali+ed# 7ndications for
referral and the management of exacerbations of $DP) in the hosital deend on local
resources and the facilities of the local hosital#
nti$iotics: Antibiotics should be given to atients*
" 9ith the following three cardinal symtoms* increased dysnea& increased sutum volume&
increased sutum urulence " 9ith increased sutum urulence and one other cardinal
symtom
" 9ho re-uire mechanical ventilation
!I