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Information on the screening, classification, and management of α-1 antitrypsin deficiency and copd. It covers the risk factors, symptoms, and diagnostic tests for α-1 antitrypsin deficiency. The document also outlines the stages and characteristics of copd, as well as strategies for reducing risk factors, quitting smoking, and managing symptoms using various pharmacologic and non-pharmacologic interventions.
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Definition contd..
ATS
Airflow Limitation Reversibility
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Diagnosis
Measurement of Airflow Limitation
{ Gold standard for diagnosis and assessment of COPD
{ Postbronchodilator FEV1 < 80% of predicted value + FEV1/FVC < 70% - confirms airflow limitation that is not fully reversible
{ FEV1/FVC more sensitive FEV1/FVC < 70% - early sign of airflow limitation when FEV1 remains normal (≥ 80% predicted)
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Measurement of Airflow Limitation
o PEF good substitute if spirometry not available In COPD PEF may underestimate degree of airways obstruction
o Prolongation of FET > 6 sec → crude guide to FEV1/FVC ratio < 50%
o 6 minute walking test performed by measuring distance covered in 6 minutes when patient walks at his/her own speed (under physician supervision) o can be performed at the primary care level
Bronchodilator reversibility testing
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Measurement of Airflow Limitation
{ Ratio of inspiratory to total lung capacity - an independent risk factor for mortality in patients with COPD *
{ This ratio may be a better assessment tool than FEV
{ Inspiratory capacity and lung volumes may better reflect the functional response and the improvement of symptoms and exercise tolerance induced by bronchodilator agents
BODE index
{ BODE index (Body mass index, airflow Obstruction,
Dyspnea, and Exercise capacity) - a stronger predictor than FEV1 of the risk of hospitalization and death among patients with COPD '
{ Might provide useful prognostic information
' N Engl J Med 2004;350:1005– ' Chest 2005;128:3810–
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Exercise testing
o Functional exercise capacity - the strongest correlate of physical activity in daily life
o Recommended for more comprehensive evaluation of severity and response to treatment
o Endurance shuttle test - sensitive test for detecting changes in exercise capacity induced by bronchodilators ' and rehabilitation
' Am J Respir Crit Care Med 2005;172:1517–
ABG
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Classification of Severity
Stage
0: At Risk
I: Mild COPD
II: Moderate COPD
III: Severe COPD
IV: Very Severe
Characteristics
. normal spirometry . chronic symptoms (cough, sputum production) . FEV1/FVC < 70% . FEV1 ≥80% predicted ± chronic symptoms (cough, sputum production) . FEV1/FVC < 70%. 50% ≤FEV1 < 80% predicted . ± chronic symptoms (cough, sputum production) . FEV1/FVC < 70% . 30% ≤FEV1 < 50% predicted . ± chronic symptoms (cough, sputum production) . FEV1/FVC < 70% . FEV1 < 30% predicted or FEV1 < 50% predicted + chronic respiratory failure
Ongoing monitoring and assessment
{ Monitor disease progression and development of complications (JVP,pitting ankle edema s/o RVF), symptoms of hypercapnia (bounding pulse, warm extremities, flaps and tremulousness) & hypoxia (tremors, restlessness, mental obtundation and cyanosis)
Spirometry - if increase in symptoms or a complication
{ Monitor pharmacotherapy and other medical Rx
{ Monitor exacerbation sputum volume / dyspnea / purulent sputum
{ Monitor Comorbidities LVF, Ca bronchus, PTB, sleep apnea,
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Reduce risk factors
General measures
{ (1) avoiding open burning of crop residue
(2) use of water to suppress dust (3) wearing masks at work place in areas of dust generation
{ use of smokeless ‘chullahs’
{ Substitution of solid fuels with LPG or electricity is the best approach
Quit rates { Placebo 6% { NRT and behavioural therapy 9% { Bupropion (6-9 wks) 18% at 1 yr
Bullectomy Lung Volume Reduction Surgery (LVRS) Lung Transplantation
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General principles
{ None of the existing medications shown to modify long-term decline in lung function { Smoking cessation and continuous long-term oxygen treatment only pharmacologic interventions that modify natural history of COPD
{ Stepwise increase in treatment
{ Treatment response variable
Bronchodilators
{ Bronchodilator medications are central to symptom management in COPD
{ Inhaled therapy preferred
{ Choice between ß2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects
{ Bronchodilators prescribed on an as-needed or on a regular basis to prevent or reduce symptoms
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ß2-agonists
Relax airway smooth muscle by stimulating ß2- adrenergic receptors, which c-AMP Oral therapy slower in onset & more side effects o Resting sinus tachycardia o Tremor o Hypokalemia o O 2 consumption show tachyphylaxis
IV: Very Severe
III: Severe
II: Moderate
0: At I: Mild Risk
New (2003)
Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add i nhaled glucocorticosteroids if repeated exacerbations Add l ong-term oxygen if chronic respiratory failure Consider surgical treatments
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ß2-agonists
Salmeterol 25-50 (MDI & DPI) 12+
Formoterol 4.5–12 (MDI & DPI) 12+
Long-acting
Terbutaline 400, 500 (DPI) 4-
Salbutamol 100, 200 (MDI & DPI) 4-
Fenoterol 100-200 (MDI) 4-
Short-acting
Duration of Drug Inhaler(ug) Action (hrs)
Anticholinergics
Salbutamol/Ipratropium 75/15 (MDI) 6-
Fenoterol/Ipratropium 200/80 (MDI) 6-
Combination
Tiotropium 18 (DPI) +
Long-acting
Oxitropium bromide 100 (MDI) 7-
Ipratropium bromide 20, 40 (MDI) 6-
Short-acting
Anticholinergics
Duration of Drug Inhaler (ug) Action (hrs)
4, 8, 16 mg Methyl-prednisolone 10-2000 mg (Pill)
5-60 mg Prednisone (Pill)
Systemic glucoco rticosteroids
25/50, 125, 250 (MDI)
Salmeterol/Fluticasone 50/100, 250, 500 (DPI)
(9/320) (DPI)
Formoterol/Budesonide 4.5/80, 160 (DPI)
Combination
Triamcinolone 100 (MDI) 40
Fluticasone 50-500 (MDI & DPI)
0.20, 0.25, Budesonide 100, 200, 400 (DPI) 0.
Beclomethasone 50-400 (MDI & DPI) 0.2-0.
Oral
Solution Drug Inhaler for
{ long-term inhaled steroids reduce mortality from all causes in patients with COPD
Thorax 2005;60:992–
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Tiotropium
{ Tiotropium, a long-acting anticholinergic agent,reduces frequency of exacerbations & use of health care resources in patients with moderate to severe COPD
Ann Intern Med 2005;143:317–
Theophylline
{ Oral theophylline only if inhaled treatments have failed to provide adequate relief
{ All studies that have shown efficacy of theophylline in COPD were done with slow-release preparations
{ Addition of theophylline to ß2-agonists or anticholinergics may produce additional improvements in lung function and health status
{ Combination of salbutamol with theophylline in a single tablet not recommended