Discussion Risk factors or epidemiology COPD is defined by the WHO/NHLBI as 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 gases” (Stern 2010). Clinical manifestations of COPD include exercise intolerance, progressive dyspnea, and cough with sputum production. The most important predisposing factor for developing COPD is a prolonged smoking history. Other significant risk factors include occupational exposure, environmental pollution, socio-economic status, genetic factors, sex, recurrent bronchopulmonary infections, perinatal events, childhood illness and history of airway hyperreactivity (Celli 2004). Diagnostic work up/Tests/Interpretation of Testing Diagnosis of COPD is made based on history, physical exam and results of pulmonary function tests. Important aspects of the history include history of symptoms such as chronic cough, sputum production, dyspnea, decreased exercise tolerance, exposure history, frequent colds, unexplained weight loss, and family history. Respiratory rate, weight, height and BMI should be assessed. In the initial stages of COPD, patients often have an entirely normal physical exam (Fauci 2011). In more severe disease, the physical exam can be notable for a prolonged expiratory phase and expiratory wheezing. Signs of hyperinflation on physical exam include a barrel chest or poor diaphragmatic excursion. Other physical findings often present in severe COPD include use of accessory muscles and cyanosis often visible in the lips and nail beds (Harrisons). Results of spirometry are also a necessary part of the diagnosis of COPD. Pulmonary function tests show airflow obstruction with a decreased FEV1 and FEV1/FVC. The degree of airflow obstruction as determined by FEV1 and FEV1/FVC is important is staging COPD using Gold’s criteria. FRC and RV are increased due to air trapping. DLCO is decreased secondary to alveolar destruction. Since COPD is not reversible with bronchodilator therapy, in order to distinguish COPD from asthma, PFT are most valuable when measured after bronchodilator therapy. Chest radiography is not useful in the diagnosis of COPD but is suggested in order to rule out other causes of presenting symptoms. In addition, chest radiography could be helpful in classification of the type of COPD (Fauci 2011). Arterial blood gas and oximetry are important in assessment of exacerbation because they provide information about alveolar ventilation and acid base status. Indications for admission Indications for admission for patients with COPD exacerbation include inadequate response to outpatient medications, worsening hypoxemia or hypercapnia, mental status changes, marked increase in dyspnea, existence of comorbid conditions, and inadequate home care (Celli 2004). Respiratory failure and/or hemodynamic instability are indications for ICU admission (Celli 2004). Management and Prognosis Treatment of COPD includes nonpharmacologic and preventive interventions as well as pharmacologic therapy. Preventive and nonpharmacologic therapy includes smoking cessation or removal of toxic agent, exercise programs and vaccination against influenza and pneumococcal pneumonia (Stern, 2010). Initial therapy for symptomatic patients is an anticholinergic inhaler such as ipratropium or tiotropium. A short acting β agonist is useful if the patient still symptomatic. The β agonist can be given on a scheduled basis or as needed. Theophylline can be used in patients who do not respond to anticholinergics and β agonists. Theophylline has been found to produce modest improvments in expiratory flow rates and a small improvement in arterial oxygen and carbon dioxide levels in patients with severe COPD. The effectiveness of theophylline is limited by its narrow therapeutic index (Stern). The benefit of inhaled corticosteroids is controversial. Some studies show benefit from regular use of inhaled corticosteroids while other studies do not (Fauci 2011). Supplemental oxygen is indicated in patients with

In patients with severe COPD as indicated by significant hypoxemia and CO2 retention. J. R. Hauser. Symptom to diagnosis: an evidence-based guide. L. McGraw-Hill Medical. J.. 2. Respir. As the disease progresses complications resulting from exacerbations such as respiratory failure. D. . Howard. 4. Exacerbations are also treated with systemic corticosteroids for a period of two weeks. 1995. C. Decramer. Respir. Postma. and A. B. Celli. Higenbottam. J. P. P. M. Kasper. Patients with acute exacerbations are often treated prophylactically with antibiotics. 2011. J. E. Hodgkin JE. This has been shown to reduce length of hospital stay and reduce recovery time. S. Gibson. N... Treatment of COPD exacerbation is an important part of COPD treatment. 2009. J. Paoletti. 5. T. London. Clin Chest Med 1990. Eur. The most important factors that effect the prognosis of patients with COPD are the patient’s age and the patient’s baseline postbronchodilator FEV1. B. Braunwald. C. cor pulmonale and lung cancer become more likely (Siafakas 1995). The European Respiratory Society Task Force. Longo. J. Supplemental oxygen therapy is the only pharmacologic therapy that has resulted in decreasing mortality of patients with COPD (Fauci 2011). Cifu. and D. 2004.. Fauci. L. 23:932-946. S. Patients who stop smoking are more likely to live longer than patients who do not. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. D.resting hypoxemia or cor pulmonale. They can be precipitated by bacterial infection or viral respiratory infection. S. Vermeire. P. New York. S. Altkorn. and ATS/ERS Task Force. References 1. W. Stern. Pride. Yernault. Jameson. and D. Prognosis in chronic obstructive pulmonary disease. Siafakas. A. Harrison's Principles of Internal Medicine. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). D. M. Eur. 8:1398-1420. Loscalzo. MacNee.11:555–569. supplemental oxygen has shown to decrease mortality (Hodgkin 1990). N. 3. S. Exacerbations are episodes of increased dyspnea and cough often accompanied by change in sputum. McGraw-Hill distributor.

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