COPD (eBook)

1: The Multiple Components of COPD 15
Introduction 16
Structural Changes 16
Pulmonary Inflammation 19
Inflammatory Mediators 20
Systemic Inflammation 22
Systemic Consequences and Comorbidities 23
Chronic Heart Failure 24
Diabetes 24
Atherosclerosis 25
Osteoporosis 26
Muscle Wasting 26
Conclusions 27
References 27
2: Clinical Assessment of COPD 35
Diagnosis and Differential Diagnosis 35
Symptoms in COPD 38
Breathlessness 38
Cough and Sputum Production 40
Wheezing 40
Fatigue 40
Other Symptoms 40
Assessment of the Patient Suspected of COPD 41
History 41
Physical Signs 41
Body Habitus 42
Lung Function Tests 42
Arterial Blood Gases 42
Exercise Testing 43
Blood Tests 43
Radiology 43
Electrocardiography and Echocardiography 44
Assessment of the Patient with Acute Exacerbation of COPD 44
Summary 44
References 44
3: Physiologic Assessment of COPD 46
Introduction 46
Making the Diagnosis 47
Evaluation of Disease Severity 48
Measurement of Airway Function 48
Measurement of Lung Hyperinflation 50
Measurement of Gas Transfer 51
Testing Airway Reversibility 51
COPD Versus Asthma 52
Evaluation of Exercise Performance 53
Field Tests 53
Cardiopulmonary Exercise Tests 54
Testing for Complications of COPD 59
Composite Scoring Systems of Severity 60
Monitoring Disease Progression 60
Evaluation of Therapeutic Interventions 61
Conclusions 62
References 63
4: Outcome Measures and Prognostic Markers for COPD 71
Introduction 71
Lung Function 72
Patient-Reported Outcomes 73
Dyspnoea 74
Health Status 74
Exercise Capacity 75
Exacerbations 76
Mortality 78
Imaging 79
Biomarkers 80
Non-pulmonary Markers 81
Body Weight and Fat-Free Mass 82
Measurement of Quadriceps Muscle Function 82
The Conclusions of the Report of the ATS/ERS Task Force on the COPD Outcomes 83
References 84
5: Management Guidelines for Chronic Obstructive Pulmonary Disease 92
Introduction 92
COPD Is Highly Prevalent, Under-Diagnosed, Under-Treated and Under-Perceived 93
COPD a Multicomponent Disease 93
COPD, a Treatable Disease 95
Therapy Is Effective for the Respiratory Manifestations of COPD 95
Smoking Cessation and Decreased Exposure to Biomass Fuel 95
Pharmacological Therapy of Airflow Obstruction 96
Bronchodilators 96
Beta-agonists: 97
Anticholinergics: 97
Phosphodiesterase Inhibitors: 97
Anti-inflammatory Therapy 98
Corticosteroids: 98
Combination Therapy 99
Mucokinetic 99
Antibiotics 99
Alpha 1-Antitrypsin 99
Vaccination 100
Lung Volume Reduction 100
Therapies That Are Effective for the Nonrespiratory Manifestations of COPD 100
Pulmonary Rehabilitation 100
Supplemental Oxygen Therapy 101
Exacerbations 101
Conclusion 102
References 102
6: Pharmacological Therapy: Bronchodilators 110
Introduction 110
Rationale for the Use of Bronchodilators in COPD 112
Current Bronchodilators in COPD 113
b2-Adrenoceptor Agonists 114
Pharmacology 114
Clinical Benefits 114
Role of Stereoisomers 114
Non-bronchodilator Effects of b2-Agonists 115
Anticholinergics 115
Pharmacology 115
Clinical Benefits 115
Non-bronchodilator Effects of Anticholinergics 116
Methylxanthines 116
Pharmacology 116
Combination Therapies 116
Bronchodilator Combination Therapy 116
LABA.+.Inhaled Corticosteroid Combination Therapy 117
Anticholinergic.+.Inhaled Corticosteroid Combination Therapy 117
Delivering Bronchodilators to the Lung 117
Safety of Bronchodilator Therapy in COPD 118
Novel Bronchodilators 119
Novel b2-Agonists 119
Novel Anticholinergics 120
Phosphodiesterase-4 Inhibitors 120
Conclusions 120
References 120
7: Pharmacological Therapy: Inhaled Corticosteroids 126
Introduction 126
Do Inhaled Corticosteroids Have Any Anti-inflammatory Effect in COPD? 127
Do Inhaled Corticosteroids Change Important Clinical Endpoints in COPD? 128
Decline in Lung Function 128
Clinic Lung Function 129
Health Status or Quality of Life 131
Exacerbations 131
Mortality 132
What Side Effects Are Associated with Inhaled Corticosteroid Use? 134
How Should We Use Inhaled Corticosteroids in Our Clinical Practice? 135
Conclusion 136
References 136
8: Pharmacological Therapy: Novel Approaches 139
Introduction 139
Advances in Current Therapeutic Strategies 141
Improvement in Delivery 141
Bronchodilators 142
Reduction in Toxicity 142
Advantages of Combinations 143
Smoking Cessation 144
Anti-inflammatory Therapies 145
Rationale and General Considerations 145
PDE Inhibitors 146
PDE5 146
PDE4 146
Anti-oxidants 147
Anti-proteases 147
Alpha-1 Protease Inhibitor 147
Other Protease Inhibitors 148
Anti-TNF-a 148
Currently Available Drugs That May Have Anti-inflammatory Actions in COPD 149
Macrolides 149
Theophylline 149
Statins 149
Cough and Mucus 150
Pulmonary Vasculature 150
Systemic Effects 151
Lung Regeneration 151
Conclusion 152
References 152
9: Smoking Cessation 158
Introduction 158
Epidemiology of Cigarette Smoking 159
Brief Intervention 159
Basic Neurobiology of Smoking 162
Assessment of Nicotine Dependence 163
Pharmacological Treatment 163
Nicotine Replacement Therapy 163
Nicotine Product Choices 165
Safety of NRT 166
Combination Nicotine Products 166
Bupropion 167
Varenicline 167
Second Line Medications for Smoking Cessation 168
Clonidine 168
Recent Advances in Smoking Cessation Therapy 169
Conclusion 170
References 171
10: Pulmonary Rehabilitation 175
Introduction 176
Definition and Rationale of Pulmonary Rehabilitation 176
Respiratory and Systemic Consequences of COPD 178
Respiratory Limitations 178
Peripheral Muscle Dysfunction 179
Respiratory Muscle Dysfunction 180
Cardiac Abnormalities 180
Nutritional Abnormalities 180
Skeletal Abnormalities 180
Psychosocial Factors 180
Why Pulmonary Rehabilitation Works 181
Selection Criteria for Pulmonary Rehabilitation 181
Goals of Pulmonary Rehabilitation 182
Components of Pulmonary Rehabilitation 182
Assessment 182
Exercise Training 182
Education and Self-management Strategies 183
Nutritional Intervention 184
Psychological and Social Considerations 185
Settings of Pulmonary Rehabilitation 185
Pulmonary Rehabilitation as Part of Integrated Care 185
Developing Areas in the Science and Application of Pulmonary Rehabilitation 186
Activity and Exercise in COPD 186
Initiating Pulmonary Rehabilitation Immediately Following the COPD Exacerbation 187
Lung Hyperinflation and Exercise Training in COPD 188
Enhancing Exercise Training Effects in Pulmonary Rehabilitation 188
Bronchodilators 189
Supplemental Oxygen 189
Maintaining the Benefits of Pulmonary Rehabilitation 190
Combination Therapy for COPD 190
Summary 190
References 191
11: Exacerbations of COPD 199
Introduction 199
Definitions and Spectrum of Patients with AECOPD 199
Cost, Morbidity, and Mortality of Severe AECOPD 200
Common “Do’s” and “Don’ts” in AECOPD 203
“Do’s”: Factors Shown to Be Helpful in Patients with AECOPD 203
“Don’ts”: Factors That Are Not Helpful in Patients with AECOPD 204
Factors Associated with Frequent Exacerbations 204
The Use of Antibiotics, the Specific Antibiotic Choice, and the Impact of Treatment Failure 205
Clinical Parameters to Stratify Patients into Risk Groups 208
Prevention 210
Summary 213
References 213
12: Home Management Issues 218
Introduction 218
Long Term Oxygen Therapy 219
Oxygen Sources 220
Oxygen Delivery Devices 220
Oxygen-Conserving Devices 221
Prescribing Home Oxygen Therapy 222
Patient Education and Compliance 222
Ventilatory Support 222
Methods 224
Indications 226
Home Follow Up 226
Home Rehabilitation 227
Summary 228
References 228
13: Co-Morbidities and Systemic Effects of COPD 232
Introduction 232
Prevalence of Co-Morbidities in COPD 233
Muscle Wasting 234
Prevalence of Muscle Wasting 234
Pathogenesis of Muscle Wasting 235
Consequences 237
Management 237
Hormonal Disturbances in COPD 239
Growth Hormone/Insulin-Like Growth Factor-I in COPD 239
Thyroid Hormone in COPD 240
Testosterone in COPD 241
Bone Disturbances in COPD 242
Disturbances in Fluid Homeostasis 244
Cardiovascular Morbidity and Mortality 245
Conclusions 247
References 248
14: Non-Pharmacological and Surgical Management of COPD 255
History of Nonpharmacological Therapy for Emphysema 255
Techniques 256
Bullectomy 256
LVRS Without Giant Bullae 256
Bronchoscopic Lung Volume Reduction 256
Lung Transplantation 257
What Are the Results of Nonpharmacological Therapies? 257
Bullectomy 257
LVRS Without Giant Bullae 257
Lung Transplantation 260
Which Patients Should and Which Should not Be Considered for Nonpharmacological Therapy? 261
Bullectomy 262
Lung Volume Reduction Without Giant Bullae 263
Lung Transplantation 266
Lung Transplantation Versus LVRS 269
Conclusions 269
References 270
15: Depression and Anxiety in COPD: Diagnosis and Management Issues 277
Introduction 277
Overview: Depression and Anxiety in COPD 278
Diagnosing Depression and Anxiety 278
Treatment 280
Organizing Clinical Practice to Improve Mood Disorders in COPD Patients 283
Talking with Patients About Mood Problems 284
Conclusion 284
References 285
16: Disease Management Programs for COPD 288
Introduction 288
Improving Chronic Illness Care: Shift of Focus from Acute to Chronic Care 289
The CCM Components 290
Self-management Support 291
Delivery System Design 292
Decision Support 292
Clinical Information Systems 292
Self-management in COPD 292
Definition of Self-management Model (Self-efficacy) 292
Review of the Benefits of Self-management 294
Building Self-management Strategies in COPD 295
Action Plan in COPD 297
Summary 298
Clinical Implications 298
Future Research 300
References 300
17: General Management Issues in COPD: Sleep, Travel and Preoperative Management 303
Sleep Disorders in COPD 304
Normal Respiratory Physiology During Wakefulness, Sleep, and During the Transition from Wakefulness to Sleep 304
Control of Respiratory Function 304
Upper Airway Function 305
Lower Airways Function 305
Respiratory Pump 305
Chemoreceptors 305
Sleep Disorders in Patients with COPD 306
Insomnia 306
Obstructive Sleep Apnea 308
Travel and Residence at High Altitude 309
Effects of Altitude on Respiratory System 309
Evaluation and Prescription for Supplemental O2 at High Altitude 310
Preoperative Care of Patient with COPD 311
Pre-Operative and Perioperative Strategies for Elective Major Surgical Procedures in COPD Patients 312
Post-operative Management of Elective Surgical Procedures in COPD Patients 313
Summary 313
References 314