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 ????

5) 6) 7)

8)

9)

10) 11) 12)

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