Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease usually caused by exposure to tobacco smoke. It is characterized by airflow limitation that is not fully reversible. This disease is associated with an abnormal inflammatory response of the lungs to noxious particles of gases, chronic airway irritation, mucus production, and pulmonary scarring and changes in pulmonary vasculature (Ferri, 2018).
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Exacerbation and comorbidities may contribute to the overall condition and prognosis in individual patients. In the United States, 14% of adults between the ages of 40 to 79 years are affected with COPD, with the highest incidence in males greater than 40 years of age (Ferri, 2018).
Ferri (2018), states that between 10% and 20% of COPD in the US is due to occupational or other exposure to chemical vapors, fumes, and irritants; 80% to 90% is due to cigarette smoking. Ferri (2018) further states that COPD is accountable for 16 million office visits, 500,000 hospitalizations, 120,000 deaths annually, and greater than $18 billion in direct health care costs annually can also be distributed to COPD.
Physical assessment starts with obtaining a thorough history, which includes patient’s smoking history, occupational exposures, and family history of lung disease. Patients may have a history of productive cough, wheezing, and shortness of breath, especially with exercise. Patients may also complain of fatigue due to disruptive sleep secondary to constant nocturnal cough and persistent hypoxia and hypercapnia (Sharifabad, 2017).
According to Ferri (2018), COPD has been divided into two major groups based on their phenotype, the blue bloaters, and pink puffers. He further explains that blue bloaters are patients with chronic bronchitis and their bluish tinge color of skin is because of chronic hypoxemia and hypercapnia, and the frequent presence of edema. They have a chronic cough with the production of large amounts of sputum. Then he stated that pink puffers are patients with emphysema and their pink skin color due to their adequate oxygen saturation. Pink puffers manifest their shortness of breath by pursed-lip breathing and use of accessory muscles of respiration.
On physical examination, patients may present differently depending on the severity of the COPD. Patients in the early stage of COPD, their exam may be normal or present with prolonged expiration or wheezes on forced exhalation. Patients may also present with tachypnea, respiratory distress, intercostal retraction, and use of accessory muscles in a more advanced stage of the disease. In end-stage COPD, patients may adopt positions that relieve dyspnea, such as leaning forward with arms outstretched and weight supported on the palms or elbows (Han, Dransfield, and Martniez, 2017).
The best treatment plan for COPD is to prevent and control the symptoms. Reducing the severity and number of exacerbation, improve respiratory capacity for increased exercise tolerance, and to reduce mortality (Sharifabad, 2017). Treatment is individualized depending on patient’s health status and co-morbid conditions. According to Sharifabad (2017), the GOLD guidelines are a stepwise approach to pharmacologic therapy for groups A-D.
- These guidelines for group A patients which are considered patients with few symptoms and low risk of exacerbation. Their first-line therapy is a bronchodilator, short or long-acting.
- For group B patients which are patients with more symptoms and low risk in an exacerbation. Their first-line therapy is a long-lasting bronchodilator, or two bronchodilators may be warrant for patients with severe breathlessness.
- For group C patients which are considered patients with few symptoms but a higher risk of exacerbation. Their first-line therapy is a long-acting bronchodilator and GOLD recommends starting a long-acting muscarinic antagonist (LAMA) in this group. Patients with further exacerbation may also benefit from adding a second long-acting bronchodilator (long-acting beta-2-agonist [LABA] or LAMA) or a combination of a LABA and an inhaled corticosteroid (ICS).
- Lastly, group D patients which are patients with more symptoms and high risk of exacerbation, GOLD recommends starting therapy with a LABA/LAMA combination. In some cases, they may escalate treated patients with LABA/LAMA/ICS if they still have exacerbations then other options may consist of adding roflumilast, or a macrolide, or stopping the ICS (Sharifabad, 2017).
Education consists of smoking cessation, including pharmacotherapy and counseling. Avoidance of air pollutants and environmental exposure to toxic fumes. Patients should be educated on the importance of receiving the pneumococcal vaccine and the yearly influenza vaccine. Eating a healthy diet and physical activity should also be recommended for all patients with COPD.
Follow-up
Patients should be monitored closely depending on the severity of disease. Patients with mild stable COPD may be followed up to 6 months intervals, while severe and frequent exacerbation and recently hospitalized patients should be a follow-up at 2 weeks to 1-month intervals. During the follow-up sessions, patients should be evaluated to determine adherence to medical regimen, response to therapy, and disease progression.
References
Ferri, F. F. (2018). Ferri’s Clinical Advisor 2018: 5 Books in 1 (Ferri’s Medical Solutions)
Han, M., Dransfield, M., & Martinez, F. (2017). Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging. Retrieved from https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-clinical-manifestations-diagnosis-and-staging?
Sharifabad, M. (2017). COPD Definition – Epocrates online. Retrieved from https://online.epocrates.com/diseases/721/COPD/Definition
