Health Care Options in Vaughan, Ontario, Canada

COPD Program

Management of chronic obstructive pulmonary disease (COPD) includes the management of chronic stable disease and the management of exacerbations.

Treatment for acute exacerbations includes measures such as:

The speedy goal of therapy is to ensure adequate oxygenation and normalization of blood pH, elimination of airway obstruction and influence on the causes.

The causes of an exacerbation typically go unrecognized, although some exacerbations are caused by infections. Smoking, inhalation of irritants and air pollution can also cause an exacerbation.

Mild worsenings can be managed at home. Elderly frail patients and patients with concomitant diseases, previous respiratory failure or acute abnormalities in the blood gas composition should be referred to a hospital. Patients with severe disorders should be referred to the intensive care unit, where there is the possibility of frequent monitoring of respiratory status.

Oxygen support

Many patients need oxygen support during an exacerbation of chronic obstructive pulmonary disease. Hypercarbia or CO2 retention may increase with oxygen administration. Usually, this increase is considered a consequence of the weakening of the hypoxic activation of the respiratory center. However, the increased mismatch in ventilation-perfusion ratios (V / Q) is probably a more important factor.

Prior to the appointment of oxygen therapy, the V / Q ratio decreases with vasoconstriction of the pulmonary vessels due to a decrease in perfusion in poorly ventilated areas of the lungs. An increase in V / Q mismatch arises from a decrease in hypoxic pulmonary vasoconstriction when oxygen is administered.

Hypercapnia may be enhanced by the Haldane effect, but this version is questionable. The Haldane effect is to reduce the affinity of hemoglobin to carbon dioxide, which leads to an excess accumulation of carbon dioxide dissolved in the blood plasma. Oxygen therapy is recommended, however in some cases it may aggravate hypercapnia; many patients with chronic obstructive pulmonary disease may have hypercapnia, and therefore severe CNS depression is unlikely if PaCO2> 85 mm Hg. Art. The target level for PaO2 is about 60 mm Hg. Art .; higher levels do not have much effect, but increase the risk of hypercapnia.

For patients prone to hypercapnia (for example, an increased serum bicarbonate level may indicate compensated respiratory acidosis), oxygen is administered through nasal cannulas so that oxygen supply can be carefully controlled. Patients whose condition aggravates after oxygen therapy require additional ventilation.

Ventilation support

Non-invasive supply and exhaust ventilation (for example, pressure support or dual supply and exhaust ventilation with a face mask) is an alternative to full mechanical ventilation. Non-invasive ventilation appears to reduce the need for intubation, decrease hospital time and reduce mortality in patients with severe exacerbations (defined as pH 60 mm Hg. Art., a significant limitation of physical activity and severe violations of the nutritional status. However, consent from high-risk patients for intubation and mechanical ventilation should be obtained and documented as long as their condition is stable and they are followed up on an outpatient basis. However, addressing the possible need for ventilation should not delay the management of acute respiratory failure; many patients requiring mechanical ventilation may return to their pre-exacerbation baseline.

Also, the method of nasal high-flow oxygen therapy was tested in patients with acute respiratory failure on the background of exacerbation of chronic obstructive pulmonary disease and can be prescribed to those who cannot tolerate non-invasive ventilation with a mask.

For patients requiring prolonged intubation (eg, more than 14 days), a tracheostomy is indicated to improve comfort, communication and food intake. Many patients who require long-term mechanical ventilation are prescribed a pulmonary rehabilitation program that includes proper nutrition and psychological assistance. There are individual programs for patients who remain ventilator-dependent after acute respiratory failure. In some patients, the ventilator can be turned off for the whole day. Educating family members of patients with adequate home care may allow some patients to go home with a ventilator.

Drug therapy

Together with oxygen therapy (regardless of the form in which oxygen is prescribed), treatment with beta-agonists and anticholinergic drugs with or without the addition of corticosteroids should be started in order to eliminate airway obstruction. Methylxanthines, previously considered essential in the treatment of exacerbations of COPD, are no longer used; their toxicity exceeds their beneficial effect.

Beta-agonists

Short-acting beta-adrenergic agonists form the basis of drug therapy for exacerbations of chronic obstructive pulmonary disease. The most common drug is albuterol 2.5 mg via a nebulizer or 2–4 sprays (100 mcg/inhalation) from a metered-dose inhaler every 2–6 hours. Inhalation through a metered-dose inhaler provides rapid bronchodilation: there is no evidence that administration of the drug through a nebulizer is more effective than the correct administration of the same doses of the drug from a metered-dose inhaler. In cases of severe, treatment-resistant bronchospasm, long-term nebulizer therapy can be used.

Anticholenergic drugs

Ipratropium, an anticholinergic drug, is effective for exacerbations of COPD and can be given with or alternately with beta-adrenergic agonists. The dosage is 0.25–0.5 mg via a nebulizer or 2–4 sprays (17–18 mcg of medication delivered by injection) from a metered-dose inhaler every 4–6 hours. Ipratropium usually has a bronchodilating effect similar to that which occurs with the use of the prescribed doses of beta-adrenergic agonists.

The role of long-acting anticholinergic drugs in the treatment of exacerbations is not fully understood.

Corticosteroids

Corticosteroids should be prescribed urgently for all, even mild, exacerbations. Treatment options include prednisone 30–60 mg orally once daily for 5 to 7 days, with immediate discontinuation or tapering over 7–14 days, depending on clinical response. The oral alternative is methylprednisolone 60–500 mg intravenously once a day for 3 days, followed by a gradual dose reduction over 7–14 days. These drugs are equivalent in their immediate effect.

Antibiotics

Antibiotics are recommended for exacerbated patients with purulent sputum. Some doctors prescribe antibiotics experimentally for sputum discoloration or nonspecific changes on a chest x-ray. Cultures and Gram staining prior to treatment should not be performed unless an atypical or resistant microorganism is suspected (for example, in hospitalized or immunocompromised patients). Medicines aimed at eliminating the microflora of the oral cavity are indicated. Examples of effective antibiotics:

The choice of the drug is dictated by the local antibacterial resistance and the patient’s medical history. Trimethoprim/sulfamethoxazole, amoxicillin and doxycycline are prescribed for 7-14 days. An alternative first-line antibiotic is azithromycin 500 mg orally once a day for 3 days or 500 mg orally once on the first day, then 250 mg once a day from days 2 to 5.

If the patient is severely ill or there is clinical evidence that infectious agents are resistant, then broad spectrum 2nd generation drugs should be used. These drugs are amoxicillin/clavulanate 250–500 mg orally 3 times daily, fluoroquinolones (eg, ciprofloxacin, levofloxacin), and second-generation cephalosporins (eg, cefuroxime, cefaclor). These drugs are effective against the beta-lactamase-producing strains of Haemophilus influenzae and Moraxella catarrhalis, but they are more effective than the first-line drugs prescribed for most patients.

Patients need to be explained that a change in sputum color from normal to purulent is a sign of an exacerbation and that it is necessary to undergo a 10-14 day course of antibiotic treatment. Long-term antibiotic prophylaxis is only prescribed for patients who have structural changes in the lungs. Patients with frequent exacerbations should receive macrolides on a regular basis – they reduce the frequency of exacerbations but may cause undesirable side effects.

Other drugs

Lung exercises for COPD

Watch a video below demonstrating the top 3 lung exercises for chronic obstructive pulmonary disease. These exercises can also help most anyone with breathing difficulties:

COPD Support Groups

Terminal patient care

In patients with severe stages of the disease, physical activity is undesirable and daily activity is aimed at minimizing energy costs. For example, patients can limit their living space to one floor of the house, eat more often and in small portions, and avoid tight shoes. Care for the incurable patient should be discussed, including the inevitability of mechanical ventilation, the use of temporarily pain-relieving sedatives, and the appointment of a medical decision-maker if the patient is disabled.

Basic provisions