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CR - COPD + A1AT deficiency (ii) (Dx (ABG (distinguishes resp failure…
CR - COPD + A1AT deficiency (ii)
Outpatient Management goals
Dx
staging
patient education
smoking cessation
pharmacological Tx
non-pharmacological Tx
pul rehab
nutrition
exercise
Dx
Spirometry
gold-standard
PFTs
obstructive - FEV1/FVC < 70%
with < 12% reversibility after bronchodilator
clinical (symptoms + risk factors)
CXR
hyper expansion
often small heart as a result
6+ ribs seen anteriorly (normally 5th bisects diaphragm)
flattened diaphragm
HRCT
lots of black in emphysema (areas of low vasculature)
could also find early cancer
ABG
PO2 (low if <8)
PCO2
pH (normal=7.4)
could be normal due to bicarb retention
shows of there's compensation
distinguishes resp failure types
type 1: low O2, normal/low CO2
type 2: low O2, high CO2 (in COPD + asthma)
FBC (esp WCC)
U+E (renal function)
CRP (inflamm/infection)
GOLD classification
1=mild (FEV1>80%)
2=moderate (FEV1 between 50-80%)
3=severe (FEV1 between 30-50%)
4=v severe (FEV1<30%)
limitation: doesn't take symptoms into account (hence not v sensitive to degree of obstruction)
new GOLD classification has new parameters
CAT (COPD assessment test - assesses symptoms)
MMRC (modified medical research council) dyspnoea scale
Bullous emphysema
bullae = expanded air sacs pressing on surrounding lung (can be removed)
Long-term management
smoking cessation
classes
counselling
nicotine replacement
Tx
varenidine (Tx nicotine addiction)
bupropion (not used in Ire - seizure risk)
bronchodilators
3 groups
b-agonists (short or long-acting, long acting preferred)
anticholinergics (short or long-acting, long acting preferred)
methylxanthines (e.g. theophylline)
combo of b-agonists + antichols = 1st line
inhaled preferred to oral
inhaled corticosteroids
long-term if severe + frequent exacerbations are not controlled by bronchodilators
not mono therapy (more effective when combined with b-agonists)
long term oral steroids not good - SEs (e.g. pneumonia, candidasis)
vaccines
influenza annually
pneumococcal
once off if > 65
every 5 yrs if < 65 + FEV1<40%
pul rehab
aerobic lower extremity training
increased QOL, exercise tolerance, dyspnoea threshold
upper body not effective
reduced healthcare costs
Longterm O2 Tx
min = 16hrs/day
indications
PaO2 </= 7.3 or SaO2 </= 88% twice in a 3 wk period
pul hypertension
cor pulmonale
polycythaemia
NOT FOR SMOKERS - FIRE HAZARD
surgery
only for severe cases
bullectomy = laparoscopic
lung vol reduction
transplant
COPD most common cause for these
usually double