Copd Management

Chronic obstructive pulmonary disease (COPD) has become one of the major leading causes of mortality worldwide and the prevalence has increased in the last decades (Konstantikaki et al., 2011,p. 275; Macedo & Usmani 2009,p. 39). A report compiled by WHO described COPD will be the third leading of mortality rate in the world by 2020 ( Jain, Rohan, Sharma & Thakkar 2011,p.258; Macedo & Usmani 2009. p. 39.It has become a serious economic and social burden in individual, family and society/ ( Konstantikaki et al., 2011,p. 275 Macedo & Usmani 2009,p. 39). COPD often affects daily living activities and impairs the quality of life relating to health (Tashkin, & Murray 2009, p.963).

The prevalence of COPD in US is 10 million but the real figure is probably a lot higher due to under recognition and under diagnosis (Tashkin, & Murray 2009, p.963). Lin, Watkin, Johnson, Rodriguez & Barton (2008, p. 535) indicate approximately 1 in 14 adults of the U.S population has noted airflow limitation relating to COPD and suggests it is under-diagnosed in primary care. Current or past smokers in older adults have also increased prevalence of COPD (Abdool- Graffar et.al 2011, p. 63). However, an older and past or current smoker does not indicate patients have COPD, diagnosis with symptoms alone can cause over diagnosis of COPD (Lin et.al 2008, P. 357). Van Haren-Willems (2010, p.595) says there are gender prevalence differences in COPD; the prevalence is usually higher among men than women. However, the difference gap in between genders has become narrow due to the increased tobacco usage in females (Abdool- Graffar et.al 2011, p. 63). Furthermore, it is noted that the age of women with COPD is younger and have better pulmonary function compared to the male population (Naberan, Azpeitia, Cantoni, & Miravitlles 2012, p. 367). Nonetheless, the studies showed female smokers in COPD tends to have depression and anxiety related to COPD and their quality of life is poorer (Naberan et. al 2012, p.367).

Occurrence rate of COPD has increased due to risk factors. The key risk factor in the development of COPD is tobacco smoking and it contributes 90% of death among COPD; the noxious particles or gases are the major source causing inflammation in the lung and leads to this disease (Tashkin, & Murray 2009, p.963-965). Other risk factors include indoor and outdoor air pollution, occupational dusts and chemical, genetic factors, malnutrition, etc.(Foster & Provost 2012,p. 405).

Konstantikaki et al. (2011, p. 275) writes airflow limitation that is not fully reversible is the defining characteristic of COPD. The decreased ratio of force expiratory volume in 1 second to forced vital capacity (FEV1/FVC) based on spirometry is an indicator to identify the airflow limitation (Vaz et al 2009, p.1472). Air obstruction is characterized FEV1/ FVC ration post bronchodilator is less than 70%; A diagnosis of COPD is suggested to be made only with symptomatic respiratory problem if FEV1 is more than 0.8 (Achilleos & Poerie 2011, p. 23). Furthermore, the BODE index prognostic indicator is common to be used as a grading system. The score is marked from 0 to 10 in patient and it indicates the higher score patient has, the higher risk of mortality (Achilleos & Poerie 2011, p. 23 ). As the higher the airflow limitation, the higher risk of the onset of dyspnea (Vaz et al 2009, p.1472). The conditions are usually progressive and linked with lung inflammation (Macedo & Usmani 2009,p. 39). The airway caliber among COPD patients is reduced due to the inflammation and airway wall change (Fairclough & Burns 2009, p. 21). According to Seemungal & Wedzicha (2008, p. 223), symptoms of COPD range from dyspnea, cough and increased volume and purulent sputum. Exacerbations of COPD are related with persistent deterioration in the symptoms as mentioned above. As a result of the increased effort in gas exchange, hyperinflation, hyoxia and hypercapnia occur (Fairclough & Burns 2009, p. 21; Seemungal& Wedzicha, 2008,p. 223). As their incident increases with their severity, it leads to hospital admission and affects their quality of life (Seemungal& Wedzicha, 2008,p. 223). Therefore, the effective management and prevention of exacerbation of COPD is imperative in decreasing its morbidity and mortality (Seemungal& Wedzicha, 2008,p. 223).

The goals of the COPD management are early diagnosis, decrease the exacerbations rate, and lower the progression of the disease and improve the quality of life (Achilleos & Poerie 2011, p. 23). COPD management should commence with education; educating patients about the disease and let patients engaged with the symptoms control (Foster & Provost 2012, P.408).

Early detection is essential due to diagnosis often noted in advance stage of COPD (Lin, Watkin, Johnson, Rodriguez & Barton 2008, p. 535). Spirometry should be used as an indicator of diagnosis of COPD. Baseline should be obtained from the 3 reproducible satisfactory performance and the best result of Force Expiratory Volume in the 1st second (FEV1), Forced Vital Capacity (FVC), and FEV1 to FVC ratio (FEV1/FVC) needs to be documented It should be followed with a bronchodilator test to assess the difference. Significant change characterized by an FEV1/FVC ratio less than 70%, FEV1 more than 12% and >200 mL compared to the baseline (Konstantikaki et al., 2011, p.276) Furthermore, the studies from Qaseem et.al (2007,p. 663) showed that spirometry is suggested to be used in diagnosis of airflow obstruction for symptomatic patients with COPD. It is not recommended to perform in patients without respiratory symptoms (Qaseem et.al 2007,p. 663). Screening asymptomatic COPD patients is unnecessary due to the potential risk of false and side effect s from avoidable treatment (Screening asymptomatic adults for COPD using spirometry—A good idea or not t 2008, p. 107). Also, there are none published controlled studies found in relation the decrease morbidity and mortality by using spirometry (Lin, Watkin, Johnson, Rodriguez & Barton 2008, p. 535). In my opinion, spirometry use only in patients with symptoms of COPD may result in missed diagnoses; the use of spirometry in at risk individuals is imperative to detect disease in the early stage. The infrequently perform of spirometrey until the air obstruction advanced may lead under diagnosis or diagnosed too late. However, it needs cautious selection and well- trained professionals in order to indicate the effective finding in COPD.

In community, there are a couple of ways to manage COPD, education, inhaler, antibiotics, and smoking cessation. Using bronchodilators such as salbutamol and Ipratropium via inhaler or nebulizer is common as a first line treatment (Seemungal& Wedzicha, 2008,p. 224). Patients with the worsening symptoms are prescribed with antibiotics. However, it relies on physicians’ clinical judgments due to inadequate comparative studies in choosing this therapy (Seemungal& Wedzicha, 2008,p. 224). Effective management in patients on arrival in the hospital may prevent the further complication. If patient’s oxygen saturation (SaO2) is less than 90% in room air, oxygen therapy via Venturi is suggested. Same applied to the patient with arterial pressure oxygen (PaO2) is less than 8KPa. Aiming SaO2 in between 92-94% is important because the carbon dioxide retention may occur (Seemungal& Wedzicha, 2008,P. 224). The hypoxic respiratory drive is damaged in COPD patients and it may cause the risk of hypercapnia (Foster & Provost 2012, p.409). On the other hand, Qaseem et.al (2007,p. 663) says oxygen should be applied in COPD patients with hypoxemia which is PaO2 less or equal 55 mm Hg. According to Foster & Provost (2012, p.409), researches have shown that the minute ventilation is not decreased by supplemental oxygen therapy in both acute and chronic hypercapnia; the PCO2 was not shown significantly increased. Moreover, patient have severe airflow obstruction, with resting SaO2 less than 90%, Cor pulmole, cyanosis and polycythaemia, should be assessed with possibility of long term Oxygen therapy (Achilleos & Powrie 2011, p25).
Arterial blood gas (ABG) is a crucial tool to assess PH and it should be repeated in 30 minutes. X-ray and ECG should be obtained. Spirometry is also an indicator of exacerbation of COPD if a forced expiratory volum in 1 second (FEV1) is no more than 1 liter (Seemungal& Wedzicha, 2008,p. 224). Non- invasive positive pressure ventilation (NIV) is to be considered if PH in arterial is less than 7.35 which indicates respiratory acidosis (Seemungal& Wedzicha, 2008,p. 224). The intubation rate and the length of hospital stay have reduced by using NIV. Doxapram may be used if delay in administering NIV. Chest X-ray in posteroanterior is recommended in order to exclude other conditions. It may show the features in hyperinflation of lungs, flattened diaphragms, or bullous changes associated with COPD (Jain, Rohan, Sharma & Thakkar 2011,p.258; Achilleos & Poerie 2011, p.23).

Bronchodilators has been reported to be beneficial in long tern in decreasing dysponea. However, it does not indicate the improvement of airflow obstruction. Bronchodilator is used to relax the muscle of the airway and deliver oxygen to the alveolar spaces by open the airway lumen and remove carbon dioxide out (Fairclough & Burns 2009, p. 21). Bronchodilator therapy (β2-agonists and anticholinergic agents) should be commenced. Oral corticosteroids and aminophylline are recommended (Seemungal& Wedzicha, 2008,P. 224). While Abdool-Graffar et.al. suggests it is not recommended to use oral corticoststeriods as maintenance treatment in COPD patients (Abdool-Graffar et. al 2011, p. 65).Furthermore, some studies shown that Aminophylline is not significantly beneficial than other treatment and it has severe side effects such as nausea and vomiting (Nuhoglu & Nuhoglu 2008, p.306). In my opinion, bronchodilator is essential for COPD patients to management disease due to the relaxation of airway and minimal side effect. Corticoststeriods should only use in acute exacerbation of COPD not as a maintenance treatment. However, aminophylline should not be used due to insignificant benefit.

Haemophilus influenzae, streptococcus pneumoniae and Moraxella are the common type of bacteria in acute COPD exacerbation (Fairclough & Burns 2009, p. 22). Some guidelines recommend administration of antibiotic under specific to cultured microorganism (Fairclough & Burns 2009, p. 22).. However, the evidence of the benefits in COPD patient for antibiotics administration is still inconclusive (Fairclough & Burns 2009, p. 22). .
It is controversial to use antibiotics in patients as a prophylactic with an acute exacerbation of COPD due to the risk of resistant organisms (Foster & Provost 2012, p.408). There is numerous research showing physicians’ adherence to guidelines for antibiotic use as outpatient management of acute exacerbation of COPD (AECOPD) (Farkas & Manning 2010, p,173). There are limited studies discussing the use of antibiotic in acute exacerbation of COPD as inpatient management (Farkas & Manning 2010, p,173). From Chronic Obstructive Lung Disease (COLD) guidelines and current Cochrane analysis respectively, suggest that antibiotics should be considered on clinical exacerbation symptoms or patients requiring mechanical ventilation (Farkas & Manning 2010, p,175). As for antibiotic selection, broader- spectrum agents are recommended by the GOLD guidelines for patients under high risk of worsening condition (Farkas & Manning 2010, p,173). However, the narrow –spectrum antibiotic for AECOPD patients is recommended by the British guidelines, the joint guidelines, American College of Chest Physicians (ACCP) and the American College of Physicians (ACP) (Farkas & Manning 2010, p,173).

A combination of antibiotics is the common regimen used in the coverage for community- acquired pneumonia (CAP) associated with increased purulent sputum; this suggests a higher risk of possible pneumonia (Farkas & Manning 2010, p,173). However, a combination of antibiotics tends to be used very often by clinicians in patients with AECOPD due to the similarity between these two diseases (Farkas & Manning 2010, p,173). Therefore, the treatment may be required even with clear chest radiology (Farkas & Manning 2010, p,175). Then repeated x-rays after 24-48 hours should be taken to rule out the possibility of CAP (Farkas & Manning 2010, p,173). Farkas & Manning (2010, p, 177) notes there are deviations between COPD management guidelines and the antibiotic use in clinical practice. From research, patients had antibiotic treatment more suitable for community-acquired pneumonia than AECOPD while in the hospital. In my opinion, antibiotic should be given under specific to cultured microorganism after excluding the other possibility. Otherwise, patient receive unnecessary antibiotic and increase the risk of antibiotic resistant.

Vaccinations such as pneumococcal and annual Influenza should be encouraged (Achilleos & Powrie 2011, p23-26). Viruses and bacteria deteriorate airway inflammation and it leads to exacerbation of COPD. Flu vaccination annually reduces the risk of exacerbation of COPD (Burt & Corbridge 2013, p.34) Pneumococcal vaccination should to given for people over sixty- five to reduce the risk(Burt & Corbridge 2013, p.34). Moreover, pulmonary rehabilitation is suitable for recent exacerbation COPD patient required hospitalization but remains mobile (Achilleos & Powrie 2011, p24). It is including disease education, exercise, physiotherapy, nutritional support and psychological support (Achilleos & Powrie 2011, p24). It is shown the decreased hospital re-admission and improves the daily life activities (Achilleos & Powrie 2011, p24).

Smoke cessation is the most effective management in COPD (Tashkin, & Murray 2009, p.963). Tabacco smoking contributes to numerous disease and has a significant impact in most common case death such as COPD in US (Tashkin, & Murray 2009, p.963). The studies Tashkin, & Murray (2009, p.963) showed the impact of sustained smoking cessation on mild – to moderate COPD smoker is beneficial; their FEV1decline rate was half among the continuing smokers. However, the lung function loss in between intermittent quitters and continuing smoker is not remarkable. Moreover, the evidence also shown that the exacerbation rate reduced in sustained smoke quitting which lower the progression of COPD (Tashkin, & Murray 2009, p.967). Interventions for smoking cessation including physician advice, telephone quitlines, behavioral interventions, pharmacological intervention such as Nicotine replacement therapy or Bupropion sustained release (SR), Varenicline and Nicotine vaccines are recommended (Tashkin, & Murray 2009, p.969).Therefore, COPD smokers should be encouraged to commence the smoking cessation by any opportunities (Achilleos & Powrie 2011, p24). Smokers with mild to moderate COPD on smoke cessation and inhaled bronchodilator are noted to have slower decline rates of FEV1. Therefore, the education of smoke plays a crucial role in this issue (Van Haren-Willems 2010, p.596).

As for nurses’ role in management, nurses in primary and secondary prevention play an imperative role in COPD. Avoidance of pollution and smoking cessation can prevent the disease or further progression (Abdool-Graffar et.al. 2011, p.65) Comprehensive patient teaching is vital; which reinforces the learning of the treatment regimens, skill and help to prevent further exacerbation. Moreover, teaching patients to identify exacerbations and have the intervention straight away, to seek for medical advice (Bades 2012,p. 4). The inhaler technique is important to be assessed to reduce the exacerbation of COPD due to incorrect technique use by a substantial percentage patients; it causes poor treatment result and inadequate COPD management (Bades 2012,p. 4). Further facilitating and education of inhaler technique help to reduce stress, family stress, anxiety and assisting patients with self- management by gaining more confidence. Also, correct use enhances optimal effect of medication delivery and leads to the reduction of exacerbation (Bades 2012,p. 3).

Reference List

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