Classic representation of
"blue bloater" on left- hypoxia, CO2 retention, possible R heart failure.
"pink puffer" on right- preserved blood gases, cachexia, dyspnea
Most COPD patients have features of both, and this classification is not frequently used
COPD stages and therapy
(from GOLD initiative)
Stage:
0: At risk- pts with chronic symptoms, normal spirometry, exposure to risk factors
Tx: Avoid triggers, smoking cessation, flu vaccine, education
1: Mild COPD- FEV1/FVC below 70% , FEV1 over 80% of predicted, with or without symptoms
Tx: Above, and short-acting bronchodilator
Tx: Above, and regular LA bronchodilator (e.g. tiotroprium), pulmonary rehab
3: Severe COPD- FEV1/FVC below 70%, FEV1 30-50%
Tx: Above, and home O2 if PaO2 below 55
Other treatments rarely used: Theophylline, lung reduction surgery
Etiologies of exacerbations:
Majority are infection-related (80%)- H. Flu (20-30%); S. Pneumo (10-15%); M. Catarrhalis (10-15%); P. Aeruginosa (5-10%); Rhinoviruses (20-25%).
15-20% are from other causes (air pollution, irritants increasing bronchomotor tone)
Treatment components are
1) Bronchodilators (B-ag and anticholinergic)
2) Systemic steroids
3) ABx
4) Ventilatory support if needed (including BiPAP)
Abx choices:
Mild exacerbation: 1 of increased dyspnea, increased sputum purulence, increased sputum volume
Tx: No antibiotics; increase bronchodilator. Symptomatic therapy and monitoring symptoms
Moderate or severe 2 of above 'cardinal symptoms'
In complicated COPD (i.e. at least 1 of age over FEV1 below 50%, over 3 exacerbations per year)
Tx: Respiratory fluoroquinolone, amox-clav; consider cipro if risk for pseudomonas, and obtain sputum culture
In uncomplicated (i.e. none of above) Tx: macrolide, cephalosporin, doxycycline, TMP-SMX .
If abx in previous 3/12, switch classes
Steroids: Trials have demonstrated benefit of systemic steroids for vs. placebo. No mortality benefit, but shorter length of stay, PFT improvement, and symptomatic improvement.
Original trial used Solumedrol 125mg IV q8h; no advantage to this high dose over Prednisone 40-60mg PO x 5-7d. No need for taper of this duration.
Links:
Click here for a NEJM review on COPD exacerbations
Click here for the TORCH trial of inhaled corticosteroids in COPD
Click here for the GOLD initiative for COPD staging and management
1 comment :
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