CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow
that interferes with normal breathing and is not fully reversible.

  • The more familiar terms chronic bronchitis and emphysema are no longer used, but are now included
    within the COPD diagnosis.
  • Such a diagnosis should be considered in any patient who has symptoms of cough, sputum production, or dyspnea (difficult or labored breathing), and/or a history of exposure to risk factors for the disease.

A COPD exacerbation is an acute worsening of the patient’s respiratory symptoms needing a change in medications.

Causes and predisposing factors

  • Tobacco smoking is the most common cause
  • Indoor air pollution: Biomass fuel smoke (firewood, charcoal and cow dung) exposure in poorly ventilated
    kitchens
  • Exposure to occupational dust and chemicals (cement, paint, saw dust, fumes) without adequate protection
  • It may frequently follow TB disease (residual symptoms)

Clinical features

  • Chronic cough in a current or previous smoker who is over 40 years
  • Breathlessness: persistent, progressive and worse with exercise +/- tight chest and wheezing
  • Chronic sputum (mucuos) production and ‘bronchitis’ for at least 3 months in 2 successive years
  • On examination there may be a barrel chest (increased antero-posterior diameter)
  • Rapid breathing, reduced chest expansion, with or without increased use of accessory muscles of respiration, rhonchi, cyanosis
  • Decreased breath sounds, ankle swelling and other signs of right heart failure

Differential diagnosis

  • Asthma
  • Congestive Heart failure
  • Pulmonary embolism
  • Pulmonary TB

Investigation

  • Spirometry: gold standard for diagnosis but if not available use all available tools (history of exposure to risk factors + clinical symptoms + any available investigations).
  • History of exposure to risk factors
  • Chest X-ray (Hyper-inflated lungs)
  • Peak flometry
  • Echocardiography – when one suspects right-sided heart failure secondary to COPD

Management

Treatment aims at:

  • Removing risk factors and preventing further damage
  • Relief of symptoms and prevention of the severity and
    frequency of COPD exacerbations
  • Improving the patients exercise tolerance and maintaining
    good health

Inhalers are the preferred formulation for the treatment of COPD.

TREATMENT

  • Explain to the patient that:
    • COPD is chronic lung damage and there is no cure
    • Treatment is to prevent exacerbations, further damage, and infections

Non-pharmacological management

  • Advise the patient that:
    • They must stop smoking – it is the only way to stop it from getting worse
    • Reduce exposure to charcoal and wood/dung cooking smoke. Keep cooking areas wellventilated
      by opening windows and doors. Use alternative clean energy sources like Biogas,
      improved cooking stoves etc.
    • Use masks for respiratory protection or stop working in areas with occupational dust or
      pollution
    • Physical exercise to train lung capacity (pulmonary rehabilitation) under supervision
    • Get treatment quickly in case of increased breathlessness, cough or sputum
  • Physiotherapy is beneficial to improve exercise tolerance
Step 1: Mild
  • Inhaled salbutamol 2 puffs 2-4 times a day, may be used periodically for short periods. The main
    purpose of this treatment is to reduce or prevent symptoms.

If inhalers not available consider:

  • Aminophylline 200 mg twice daily
Step 2: Moderate
  • Inhaled salbutamol 2 puffs 2-4 times a day
  • Plus inhaled steroid beclomethasone 100-400 micrograms 2-4 times a day
Step 3: Severe
  • As in step 2 plus ipratropium inhaler 2 puff 2-4 times a day

Note

  • If available, long acting bronchodilators salmeterol and formeterol can be used in
    moderate and severe COPD in combination with inhaled steroids

COPD exacerbations

  • If more sputum, changed to more yellow/green coloured, and/or breathlessness, temp >38°C and
    or rapid breathing (“bronchitis”), then

    • Treat with antibiotic e.g. amoxicillin 500 mg every 8 hours for 7-10 days or doxycycline 100
      mg every 12 hours for 7-10 days
    • Oral Prednisolone 40 mg once daily in the morning for 5 days. Do NOT use oral steroids for
      extended periods in patients with COPD

Refer urgently to hospital if:

    • Rapid pulse (>100 beats per minute) or breathing (>30 breaths per minute)
    • Tongue or lips are “blue” (central cyanosis)
    • Confused
    • Failure to improve
  • Give oxygen by nasal cannula (1-3 litres/min) if available, target SpO2 88-92%

Note

  • Give oxygen with care (minimum flow required to reach the target SpO2) because COPD patients are at risk of
    hypercapnia (CO2 retention) which cause respiratory depression and coma