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COPD management summary Acute management 1) 2) 3) 4) Admit the patient Propped up and asses airway patency Take a brief

history ; known case, exacerbations, treatment regime Asses severity of COPD a. Signs : Hemodynamic instability b. Signs of right heart failure : Increase JVP, peripheral edema, parasternal heave and loud S2 c. Decrease consciousness d. Central cyanosis e. Use of accessory muscle f. Paradoxical breathing Give the patient ; venturi mask 50% oxygen Set pulse oximetry and all other vital signs ; Sa02 maitain over 90% Give Nebulised salbutamol + Ipratropium bromide a. Salbutamol 5mg and every 30 minutes if patient is not responsive b. Ipratropium bromide is given i. 0.5mg : Every 6 hours via nebuliser ii. 7 puffs : Every 3 hours via MDI Give Oral steroids 30mg daily for 7-14 days or 100-200mg hydrocortinose TDS. Then taper it down a. I think I would start oral steroids in moderate cases b. IV hydrocortisone in severe cases. However, I need to confirm with Dr. If the above fail, inform specialist whether to start a. IV salbutamol b. Slow theophylline infusion Take blood for ABG; respiratory acidosis, CO2 retention and PaO2 level Ventilate the patient if PaO2 level and acidosis could not be corrected despite venturi mask. ICU ????

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Always remember the complication of COPD : Cor-pulmonale and respiratory failure

When stable Diagnosing Spirometry : FEV1/FVC < 70% Outpatient management 1) Non-pharmacological 2) Pharmacological 3) Rehab

Non pharmacological Stop smoking Pharmacological Mild >80% Moderate 50 - <80 Severe 30 - <50 Very severe <30 or in respiratory failure

Management is in a step-wise approach Step 1 Mild and moderate Beta agonist if needed with Ipratropium bromide (Atrovent)

Add long acting beta-blocker ; if remain breathlessness after short acting Step 2 Step 3 Add steroids. ( to prevent exacerbation ; it does not improve lung function) o Need to put on trial of oral steroid. If improve, taper of oral steroid o Then Start inhaled steroids o Stop steroid if not improvement Consider ambulatory oxygen Add sustained release theophylline if overall daily fail step 1

Vaccination : influenza and pneumococcus vaccination proposed to all COPD patient Rehab 1) Exercise 2) Psychosocial 3) Breathing For MRC grade 3 Impaired QOL Frequent exacerbation

1)Exercise Upper and lower exercise ( cycling and walking 3-5 times per week) to reduce severity of dyspnea Not in Patient cannot walk Unstable angina Post MI

2) Psychosocial support ; for anxiety and depression 3) Breathing training : Diaphragmatic and purse lip training Reference 1) Malaysia COPD guidelines 2) Some from GOLD 3) Some from BTG