COPD often
co-exists with asthma and treatment therefore is similar.
COPD
includes the spectrum of chronic bronchitis (sputum production on most days for
3 months of 2 consecutive years) and emphysema (dilatation of the air spaces by
destruction of their walls). The two co-exist in varying proportions in COPD.
Clinical
features are wheeze, dyspnoea, cough and sputum; if long-standing, cyanosis and
cor pulmonale may be present. Assess how fit the patient is and how far he can
walk on the flat.
CxR shows
hyperinflation, flat diaphragms, large central pulmonary arteries but reduced
peripheral, vascular markings, bullae.
Do oxygen
saturation (pt may be used to low values; consider oxygen saturation together
with clinical signs; if very dyspnoeic and/or cyanosed, this may indicate acute
hypoxemia) and measure haematocrit to look for polycythaemia. If sputum is
purulent, ask lab to perform microscopy with gram stain.
If pt is
acutely unwell (rule out infection, left ventricular failure, sedatives,
pulmonary embolism, pneumothorax; remember that abdominal problems and other
infections may cause respiratory problems too):
-
administer
oxygen at 2-3l/min; watch carefully not to give more oxygen as this may cause
respiratory depression!!!
-
give
nebulizers: salbutamol 2.5-5 mg or terbutaline 5-10 mg and! ipratropium bromide
0.5 mg
-
give
prednisolone 20 mg (40 mg if already on steroids) and add hydrocortisone 100 mg
i.v. if very unwell unless known to be unresponsive to corticosteroids
-
prescribe
antibiotics if at least two of the following is present: increased dyspnoea,
increased sputum volume and/or purulent sputum. Amoxycillin is a standard first
choice.
-
as
last resort try aminophylline i.v. (0.5 mg/kg/h); you cannot use this if pt has
been on oral aminophylline before.
-
if pt
cannot maintain the respiratory effort (he may be exhausted, drowsy, confused),
consider intubation; consult a doctor.
On
discharge aim for maximal bronchodilation with drugs (see above). Pts who have
responded to nebulizers, will benefit from bronchodilatory inhalers. Show them
technique and give enough supply! Give follow-up appointments and treat as
indicated above.