ESTABLISH DIAGNOSIS….

Check for sputum AFB before treating chronic cough as COPD! RECOGNIZE THE EXACEBRATING FACTORS (MNEMONIC- ‘DIPLOMAT’)

·       Drugs….beta blockers

·       Infections three principle causative agents…H.Influenzae, S.Pneumoniae, M. Catarrhalis

·       Pneumothorax……has to be ruled out –X-ray chest in expiration

·       LVF….caused by hypoxia, acidosis, CO2 retention, polycythemia, Bernheim effect

·       Oxygen…hypoxic drive lost.

·       Muscle fatigue…….

·       Atelectasis……………..

·       Thromboembolism (pulmonary)……bedridden for prolonged duration.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE MANAGEMENT OF ACUTE EXACERBATION

General Measures

·       ABCs as for any critically ill patient

·       Adequate hydration: IV fluids

·       Stop or treat the Precipitating factors

·       Use Sedation with care.

·       Non invasive ventilation is useful for acute exacerbations without respiratory muscle fatiguein conscious patients.

·       Mechanical ventilation….indicated when there is respiratory arrest, refractory acidosis/hypoxia, severe respiratory muscle fatigue.

Specific Measures

·       BRONCHODILATORS…variable degree of response in patients based on reversibility of thespasm. Nebulized Ipratropium bromide (0.5 mg) is alternated with short acting beta agonists.

·       Xanthines….improves diaphragm activity (0.5-0.9mg/kg/hr aminophylline)

·       Antibiotics…….amoxycillin for H.Influenza, macrolides for Mycoplasma and S.Pneumoniae.

·       Corticosteroids……a subset of COPD patients respond to steroids; tapering over 2 wks.

LONG TERM THERAPY

·       STEROID THERAPY: Unpredictable outcome in certain subgroups; record PFT before startingand document any change after 2-3 mo.

Supplement with calcium and vitamin D.

·       INHALERS: Ipratropium, Beta 2 stimulants.

·       ORAL XANTHINES: Deriphylline.

·       OXYGEN THERAPY: Increases survival; indicated when:-

1.      COPD (Pa O2 55-59 mm of Hg) is complicated with failure of another system e.g. COR-PULMONALE, PULMONARY HT,PSYCHOLOGIC IMPAIRMENT/ HEMATOCRIT >55%

2.      Resting room air PaO2 is <55mm of Hg or saturation <89% on two occasions

3.      PaO2>60 mm of Hg. At rest but falling to <55 mm of Hg. with exercise/sleep.

At least 16 hrs / day of oxygen is recommended. Flow rate of oxygen is to be titrated afteradmitting into the hospital so as to maintain O2 saturation at 85-90% and yet not removethe hypoxic drive for respiration.

VENESECTION – If PCV > 55%, with CCF/cerebral dysfunction.