COPD

MUHAMMED KOCABIYIK  PHYSICAL MEDICINE & REHABILITATIONIV. CLASS V. GROUP

Chronic Obstructive Pulmonary Disease

• Umbrella term– Obstructive bronchitis

– Emphysema

– Asthma

• Progressive and irreversible air flow obstruction

Pathophysiology

• Bronchitis– Excess mucous blocks airways

– Chronic cough

• Emphysema– Impaired gas exchange due to destruction of

the alveolar walls

– Air trapping

Chronic Obstructive Pulmonary Disease (COPD):is the term used to describe an obstruction in the airways, due to either Chronic Bronchitis or Emphysema.

This obstruction is normally a progressive condition and may be accompanied by spasms (involuntary muscle contractions) which cause the airways to constrict although this particular problem may be partially reversible in some people.

Occupational Lung Disease (Asbestosis, Silicosis, and Coal Miner's disease) are other forms of COPD.

The degree of airway obstruction and the amount of tissue damage in the airways themselves determine the severity of the illness.

Asthma and COPD are two different diseases but they do share some common symptoms. Some Asthma patients may develop irreversible obstruction of the airways, as seen in COPD, while some COPD patients have airway spasms, as seen in Asthma.

Smoking is a major contibuting factor to COPD and should be stopped immediately.

Risk Factors for COPD

• Smoking

• Second-hand smoke

• Occupational exposure

• Air pollution

• Heredity

• Chronic respiratory infections

causes *In the vast majority of cases, smoking is the cause of COPD.

* It accounts for approximately 90 percent of all cases.

* A smoker is 10 times more likely than a non-smoker to die of COPD

  In most cases, sufferers have a smoking history of more than 20 cigarettes daily. Passive exposure to cigarette smoke and exposure to severe air pollution and toxic fumes contribute to its development.

Though a bleak prognosis, symptomatic treatment can improve the condition of the lungs. Doctors may precribe medication, along with advice on breathing techniques, moderate exercises and lifestyle changes. Optimum treatment differs from patient to patient and there are a number of medications that can be prescribed

Complications

• Pneumonia

• Acute respiratory failure

• Spontaneous pneumothorax

• Cor pulmonale

The primary symptom of COPD is shortness of breath accompanied by a cough or wheezing.

Since COPD is oftentimes a combination of emphysema and

chronic bronchitis associated with airflow obstruction, it’s important to understand the symptoms of each of these conditions.

Symptoms of emphysema include cough, shortness of breath and a limited exercise tolerance.

Symptoms of chronic bronchitis associated with airflow obstruction include chronic cough, increased mucus, frequent clearing of the throat, and shortness of breath. Remember, not all types of chronic bronchitis are associated with COPD

COPD SYMPTOMS

Clinical Manifestations of COPD

• Dyspnea• Cough• Increased work of breathing• Weight loss• Activity intolerance• Cyanosis• Diminished breath sounds• Adventitious breath sounds

Management of COPD Stage 0: At Risk

Characteristic

. Chronic s Use of clinical practice guideline symptoms. Risk factor

. Cough . Sputum

. No spirometric abnormalities

Recommend Treatment

. Adjust rist factors

. İmmunizations

Management of COPD Stage I: Mild COPD

 Characteristic• FEV1 > 80 %

FEV1/FVC < 70 %• Predicted• With or without

symptoms

 Recommend Treatment

• Short-acting bronchodilator as needed

Management of COPD

Stage II: Moderate COPD

Characteristic• FEV1/FVC < 70%• 50% < FEV1< 80%

predicted• With or without

symptoms 

Recommend Treatment

• Treatment with one or more long-acting bronchodilators

• Rehabilitation

Management of COPD

Stage III: Severe COPD

Characteristic• FEV1/FVC < 70%• 30% < FEV1 < 50%

predicted• With or without symptoms 

Recommend Treatment• Treatment with one or more

long-acting bronchodilators• Rehabilitation• Inhaled glucocortico-

steroids if repeated exacerbations (>3/year)

Management of COPD

Stage IV: Very Severe COPD

Characteristic• FEV1 < 30% predicted or presence of respiratory failure

or right heart failure

Recommend Treatment• Inhaled glucocorticosteroids if Treatment with one or

more long-acting bronchodilators• repeated exacerbations (>3/year)• Treatment of complications• RehabilitationInhaled glucocorticosteroids if Treatment

with one or more long-acting bronchodilators • Long-term oxygen therapy if respiratory failure• Consider surgical options

Physical Examination

• Inspection– Shape

– Pattern

– Rate

– Skin color

Physical Examination

• Palpation– Trachea

– Chest wall

• Percussion

• Auscultation

Abnormal Breath Sounds

• Diminished• Crackles

– Fine– Coarse

• Rhonchi• Wheezing

– Sibilant– Sonorous

• Pleural Friction Rub

Diagnostic Test

• Pulmonary Function Test

• Arterial Blood Gas

• Pulse Oximetry

• Chest Xray

• Ventilation-Perfusion Lung Scan

• Bronchoscopy

• Thoracentesis

COPD is not a reversible condition, but treatment can slow its progression. Treatments available to help manage the disease include:

• Pulmonary rehabilitation

• surgical treatment

• other treatments

What Is Pulmonary Rehabilitation?

Rehabilitation is the restoration of the patient to the fullest medical, mental, emotional, social, and vocational potential of which they are capable. Pulmonary rehabilitation is a program for patients with chronic lung disease such as emphysema, chronic bronchitis, asthma, bronchiectasis and interstitial lung disease. It includes medical management, education, emotional support, exercise, breathing retraining and nutritional counseling.

Goals Of Pulmonary Rehabilitation

• Decrease respiratory symptoms and complications

• Encourage self-management and control over daily functioning

• Improve physical conditioning and exercise performance

• Improve emotional well-being

• Reducing hospitalization

Components Of Pulmonary Rehabilitation

1. Education

This is a very necessary part of the program in the care of patients with COPD. The health care professionals of the program will provide education focused on behavioral changes and enhancing patient understanding of and adherence to prescribed therapy. The knowledge of the potential benefits of treatment will increase patient adherence to therapy.

2.Smoking Cessation

Smoking causes COPD, therefore, smoking cessation efforts are a critical part of the program. Avoiding exposure to involuntary smoke should also be encouraged. These programs offer strategies and support to patients who attempt to quit. Programs may include behavioral therapy, counseling, and medication treatment

3.Medications

Medication should be prescribed according to the severity of the disease, and the responses to and toleration of the patient for specific drugs. The following medication classes are used:

• Bronchodilators- these medications such as Albuterol can be taken up to 4 times a day or used prior to exercise. Albuterol is a short acting bronchodilator and Serevent is a long acting bronchodilator, both used to improve functional status.

• Anticholinergic- Ipratropium (atrovent) is the only and current anticholinergic and is recommended for patients who have daily symptoms. It has a slower onset and is not indicated for immediate use for relief of symptoms.

• Theophylline- is used in combination with a bronchodilator.

• Anti-inflammatory- used to reduce inflammation in the airways

• Antibiotics- treatment of infections, fever, changes in sputum volume and purulence.

• Psychoactive drugs- patients with COPD may experience symptoms, such as depression, anxiety, insomnia and pain. Underlying causes of these symptoms should be evaluated.

• Vaccination- routine immunizations for pneumonia and flu for patients with COPD is recommended.

4.Exercise Reconditioning

Exercise in patients with COPD leads to changes such as increase in the work of breathing, reduction in capacity in ventilation, increased rib cage and accessory muscle movement, expiratory abdominal muscle movement, and chest wall motion movement. Air trapping is common in patients with COPD especially during exercise and leads to alterations in functional capacity. Patients with severe COPD may breathe with the muscles of the upper chest, shoulders and neck muscles with limited or absent diaphragm contraction. Arm and leg exercise endurance testing with measurement of endurance time, metabolic, ventilatory, and cardiovascular should be determined prior to rehabilitation to determine exercise limitations and possible cardiopulmonary risk factors.

a-Exercise Training: There are positive outcomes with exercise training in patients with COPD. Patients often increase maximum exercise capacity and endurance as well as physical activity, despite lack of improvement in lung function. Exercise training also provides patients the opportunity to learn about their capacity for physical work and to practice breathing retraining techniques to control shortness of breath.

b-Arm Exercise Training: Patients with COPD report severe shortness of breath with daily activities, such as lifting and grooming, at work levels that are lower than required for leg activities. Upper extremity exercise leads to greater breathing demand for a given level of work than lower extremity exercise. Exercise training benefits are specific to the muscles used and tasks involved in training, both lower and upper extremity training are necessary in overall reconditioning.

5.Respiratory Muscle Training

Studies show an improvement in exercise tolerance and shortness of breath with respiratory muscle training. With this training carried out with controlled breathing patterns it allows high pressure generated during inspiration and has shown improvements in respiratory muscle strength and endurance and a possible increase in functional status.

6.Oxygen Therapy

Oxygen therapy is a modality of the pulmonary rehabilitation program that reduces mortality. Continuous oxygen treatment resulted in less mortality than nighttime oxygen treatment only.

In patients with reduced oxygen levels, with holding oxygen therapy leads to an early mortality. Long-term oxygen therapy is associated with alleviation of right heart failure from cor pulmonale, improved cardiac function, enhanced neuropsychological function, increased exercise performance and activities of daily living, and reduced shortness of breathing.

9.Airway Clearance

Increase mucus occurs in patients with COPD. Increased airway secretions may not correlate with airflow obstruction, but increased mucus production is associated with hospital admissions for acute exacerbations of COPD and may contribute to the risk of death in patients with severe ventilatory impairment.

During acute exacerbations of COPD, viral and bacterial airway infection, stimulate mucus production and impair clearance mechanisms. Treatments are directed toward enhancing airway secretion clearance.

8.Nutrition

Some patients with COPD are underweight which also results in pulmonary dysfunction. Malnutrition is associated with respiratory failure and increased mortality in COPD.

Assessment for malnourished states, especially in the acute care settings, is an essential early step in the care of patients with COPD and respiratory decompensation. Adequate nutrition repletion for the patient must fulfill the individual’s energy requirements, as well as incorporate the proper proportions of protein, fat and carbohydrate.

a. Coughing: during the acute exacerbations patients may cough in an ineffective manner. Patients are taught to use a controlled cough or a forced expiratory technique (huff coughing). Controlled coughing is a slow, maximal inspiration and breath holding for several seconds followed by two or three coughs. Forced expiratory are one or two forced exhalations (huffs). Huff coughing limits airway collapse, constriction of the airways, and patient fatigue. Huff coughing may be difficult for the patient who is having shortness of breath.

b. Chest Physiotherapy (CPT): CPT with postural drainage, and/or chest percussion and/or vibration, is used in patients with chronic bronchitis, bronchiectasis, and cystic fibrosis.

c. Positive Expiratory Pressure (PEP) device: involves exhaling into a device that offers resistance to exhalation which keeps the airways open during exhalation and improves expiratory flow of air. A flutter valve can also be used to help expel mucus from the lungs and works along the same theory.

Chest physical therapy

Definition

Chest physical therapy is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.

Description

Chest physical therapy can be performed in a variety of settings including critical care units, hospitals, nursing homes, outpatient clinics, and at the patient's home. Depending on the circumstances, chest physical therapy may be performed by anyone from a respiratory care therapist to a trained member of the patient's family. Different patient conditions warrant different levels of training.

Chest physical therapy consists of a variety of procedures that are applied depending on the patient's health and condition. Hospitalized patients are reevaluated frequently to establish which procedures are most effective and best tolerated. Patients receiving long term chest physical therapy are reevaluated about every three months.

Turning

Turning from side to side permits lung expansion. Patients may turn themselves or be turned by a caregiver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours round the clock.

Coughing

  Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs. Coughing is repeated several times a day.

Deep breathing

  Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods.

Postural drainage

  Postural drainage uses the force of gravity to assist in effectively draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. The patient is placed in a head or chest down position and is kept in this position for up to 15 minutes. Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Percussion and vibration may be performed in conjunction with postural drainage.

Percussion

  Percussion is rhythmically striking the chest wall with cupped hands. It is also called cupping, clapping, or tapotement. The purpose of percussion is to break up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.

Vibration

  As with percussion, the purpose of vibration is to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.

Risks

Risks and complications associated with chest physical therapy depend on the health of the patient. Although chest physical therapy usually poses few problems, in some patients it may cause • Oxygen deficiency if the head is kept lowered for drainage • Increased intracranial pressure • Temporary low blood pressure • Bleeding in the lungs • Pain or injury to the ribs, muscles, or spine • Vomiting • Inhaling secretions into the lungs • Heart irregularities.

Normal results

The patient is considered to be responding positively to chest physical therapy if some, but not necessarily all, of these changes occur: • Increased volume of sputum secretions • Changes in breath sounds • Improved vital signs • Improved chest x ray • Increased oxygen in the blood as measured by arterial blood gas values • Patient reports of eased breathing.

Evaluation

• Assess cardiac risk

• Determine appropriate exercise levels to prevent arrhythmias or hypoxia in cardiac-impaired patients

• Determine the amount of supplemental oxygen needed during exercise

• Determine need for bronchodilators during exercise

• Assess side effects of beta-agonist inhalers or aminophylline derivatives during exercise

Exercises Program

• Suggest an appropriate training mode: stationary cycling, bicycling, treadmill walking, outdoor walking, stair climbing, or arm ergometry

• Set a goal of 60% to 80% of maximum heart rate for 20 to 30 minutes, 3 days a week (but build on individual ability)

• Expect a 70% to 80% increase over initial work capacity within 6 weeks

• Provide active encouragement and reassurance (especially at first) to overcome anxiety associated with dyspnea

Here are some guidelines to follow as you start to exercise:

• Start slowly: If you can only walk (or cycle) for 2 minutes at first, do that. There's no rush. Find a pace that's right for you, and improvements will come. Your doctor will help you set appropriate personal goals.

• Be consistent: Even modest workouts will bring noticeable benefits--if you keep them up conscientiously. But if you exercise fewer than three times a week, it is unlikely to help very much.

• Break up sessions: If you can only walk for 5 minutes at a time, schedule two sessions (no more than that) on your exercise days

Exercise Aids

• Oxygen supplementation

• Bronchodilators (adrenergic agonists and/or aminophylline derivatives)

• Mucolytics

• Corticosteroids (inhaled or oral)

• Monitoring

Surgical Treatment

Lung Volume Reduction SurgeryLung Transplantation

Lung Volume Reduction Surgery

In lung volume reduction surgery (LVRS), the upper portions of the diseased lungs are removed. How the procedure improves symptoms and lung function for some patients is not well understood. Possibly, the chest wall and breathing muscles return to a place of mechanical advantage. Or perhaps the elastic recoil of the lungs improves as a result. There is a large multicenter study being performed to determine the benefits of surgery and how to qualify candidates for the procedure. The current selection criteria are very restrictive; only 20%-40% of patients qualify.

Lung Transplantation

Single or double lung transplantation may be an option for some severe cases. Many selection criteria have to be met and they vary from facility to facility.