Chronic Obstructive Pulmonary Disease -(COPD) - Hospice

Chronic ObstructivePulmonary Disease –(COPD)Diana Hart NP MN BA ACATNurse Practitioner RespiratoryDiana Hart 20131

What is COPD Chronic obstructive pulmonary disease(COPD) is a chronic respiratory conditionpresenting as slowly progressivebreathlessness, often associated withcough and sputum production. It includes both chronic bronchitis andemphysema in variable proportions in anyone patient. (Town,Garrett,Taylor &Patterson2003).Diana Hart 20132

The burden of COPDChronic Obstructive Pulmonary Disease (COPD) isestimated to affect 15% of all New Zealanders aged over45 years.It is the fourth leading cause of death in New Zealandbehind cancer, heart disease and stroke.COPD is permanent, disabling and frequently progressive.Over 85% of cases of COPD are caused by inhalation oftobacco smoke.The Asthma Foundation. COPD in New Zealand. 2012. Available from:www.asthmafoundation.org.nz (Accessed Apr, 2012)Diana Hart 20133

Management of chronic disease is arguably themost significant challenge for health caresystems. The financial and social burden from chronicdisease has been well documented, discussed anddebated. The potential for primary care to achievereductions in avoidable mortality, avoidablehospital admissions and to reduce healthinequalities has become the basis for currentgovernment policy.Diana Hart 20134

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COPD images by PeterJefferyDiana Hart 20136

Economic Burden The main costs to the health system inNew Zealand that are attributable toCOPD include medications, hospital careand primary care visits. Additional costs accrue from laboratoryservices, Emergency Department visits,smoking cessation programmes, otherlaboratory testing, and the provision ofrehabilitation services.Diana Hart 20137

Morbidity COPD results in a major deterioration inquality of life, particularly as the diseaseprogresses to the severe stage. The most significant symptom isprogressive shortness of breath limitingexercise capacity. Quality of life is also affected by poormobility and social isolation.Diana Hart 20138

Mortality In 1999, COPD accounted for 5.1% of alldeaths in New Zealand. Published mortality data in New Zealandare likely to understate the true healthburden of COPD as the cause of death inpatients with severe COPD is oftenreported as other conditions. As a consequence the true mortality maybe up to two-and-a-half times thepublished rates.(Town et al 2003).Diana Hart 20139

Prevelance Although the prevalence of asthma is quite wellunderstood in New Zealand there are no reliabledata for COPD from population surveys. World Health Organisation (WHO) globalestimates from our region suggest that around15% of adults over the age of 45 years sufferfrom COPD. This means that there are likely to be at least200,000 cases of COPD amongst adults in NewZealand of whom only 1 in 4 - 5 have had thediagnosis confirmed by a doctor(Town,Garrett,Taylor &Patterson 2003).Diana Hart 201310

Throughout western countries COPD isbecoming increasingly prevalent as theimpact of higher levels of tobacco smokingsince the 1930’s result in increasingnumbers of cases of COPD. In 1990 the WHO ranked COPD as numbertwelve in the list of diseases impacting onhealth world wide and has predicted thatCOPD will rank number five by 2020. In New Zealand it is already in the topfive.(Town et al 2003)Diana Hart 201311

In addition to tobacco smoking, theprevalence of COPD is affected bycannabis smoking and certain occupations,including bakers, food processors, spraypainters, chemical processors andagricultural workers (jobs which involveexposure to dust and chemicals). These causes account for only a smallpercentage of all cases.Diana Hart 201312

The prevalence of COPD in any givenpopulation is related to theprevalence ofsmoking and the age ofthe population. Based on hospital admission data, theprevalence for Maori is more thantwice that for non-Maori.Diana Hart 201313

COPD is often associated with otherconditions (co-morbidities) such asheart disease and is associated withan increased risk of myocardialinfarction, stroke, lung cancer andpneumonia. In many cases there is a significantadditional impact of anxiety ordepression.(Town et al 2003)Diana Hart 201314

Diagnosis is confirmed by spirometrydemonstrating air flow obstruction. As the disease progresses, symptomsbecome more prominent, lifestyle andquality of life are affected adversely and,ultimately, subjects become short ofoxygen leading to significant heartproblems. In severe cases, oxygen therapy may beprovided as part of management.Diana Hart 201315

COPD deaths occur largely in olderpeople and rates for men have beenaround twice those for women The differences between sexes isclosing and reflects the proportion ofmen and women who are currentlysmoking.Diana Hart 201316

COPD mortality rates (averaged over 3 years)in New Zealand, by sex, age group andethnicity (per 100,000)Diana Hart 201317

Depending on the number of prevalentcases, the direct costs have beenestimated at between 102m to 192mper annum. Hospital costs are estimated at 80m.perannum. The average cost per patient per year isestimated at 2,566 without consideringloss of income, the costs to family or lossof quality of life.Diana Hart 201318

Chronic Bronchitis Chronic Bronchitis is defined as hypersecretion of mucus and chronic productivecough that lasts for at least 3 months ofthe year for 2 consecutive years. The incidence is increased in smokers andalso in those workers exposed to airpollution.Diana Hart 201319

The inspired irritants increase mucusproduction and also increase the sizeand number of mucous glands andgoblet cells. The mucous is thicker and moretenacious than normal which makes itmore likely that bacteria such asHaemophilus influenza andStreptococcus Pneumoniae willbecome embedded.Diana Hart 201320

The best treatment is prevention Stop smoking. Bronchodilators and expectorantsincrease airway caliber. improvesecretion removal, and maximize gasexchange. Physiotherapy- chest clearancetechniques. Recognition of early sign of infection. Steroids for severe exacerbations.Diana Hart 201321

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Emphysema Emphysema is abnormal permanentenlargement of the acini withaccompanying destruction of alveolar wallsbut without obvious fibrosis. Septal destruction eliminates portions ofthe pulmonary capillary bed and increasesair in the acinus. Hyperinflation of alveoli causes large airspaces-bullae to develop.Diana Hart 201323

The main mechanism of airflow limitation isloss of elastic recoil. Expiration becomes difficult due to loss ofelastic recoil which reduces the volume ofair expired passively In early life it may be as a result of α1antitrypsin deficiency.Diana Hart 201324

Septal destruction also affectsairway caliber Additional airway narrowing can alsoresult from inflammatoryhyperreactivity of the bronchi withbronchoconstrictionDiana Hart 201325

Pathogenesis of COPDExposure to irritants/noxious particlesLung inflammationSmall airway diseaseAirway inflammationAirway remodelingParenchymal DestuctionLoss of Alveolar attachmentDecrease of elastic recoilAirflow limitationDiana Hart 201326

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Case Study Mr. T 67 years, married, Retiredpolice detective. Weight 64 kgsHeight 1.80 cms. Smoker 45 pack year. Used to be able to walk 5-6 kms –now about 0.5 km and he starts tobecome short of breath.Cannotattempt hills now. Past medical history hypertension. Medications Accupril 5 mgs dailyLipex 20mgs nocteDiana Hart 201328

Treatment Stop Smoking Bronchodilators: Anticholinergic agents –Ipratropium Bromide– main therapy- check MDI techniques- may needa spacer. May be able to have Spiriva B2 adrenergic agonist.- eg Salbutamol Glucocorticosteroids -small percentage helpful. Referral to Pulmonary Rehabilitation Lung Volume reduction Oxygen Therapy PaO2 7.3 kPa or 8kPa withevidence of Cor Pulmonale Annual flu vaccination and 5 yearly pneumoccalvaccineDiana Hart 201329

End of life issues Severe COPD has a five-year mortality ofabout 50%. For COPD patients who require mechanicalventilation, one-year mortality is 60%. Advance directives and end-of-life care bean integral part of the comprehensivemanagement of patients with COPD.Diana Hart 201330

Managing Breathlessness Progressive breathlessness on exertion is a keyfeature of COPD. Even every day activities such as washing anddressing can cause disabling breathlessness. Often the response to such experiences isactivity avoidance This can lead to a downward deconditioning spiralwhereby cardiovascular fitness decreases,skeletal muscle mass is lost and patientsconsequently become more breathless.Diana Hart 201331

Nutrition Normal, healthy eating advice should formpart of routine patient education in COPD. In severe COPD, however, weight loss iscommon. The mechanisms behind weightloss are not fully understood but are likelyto be a combination of systemicinflammation and a simple energyexpenditure/intake imbalance. It is associated with a poor prognosis.Diana Hart 201332

Exacerbations Exacerbations are distressing, disruptiveand disabling; the effects can last up tofour months Frequent exacerbations increase diseaseprogression and lead to significant loss ofquality of life. Advice about how to avoid them (ifpossible), and how to manage them if theyoccur is therefore important.Diana Hart 201333

Psychological problems andsocial isolation Breathlessness saps energy andconfidence, reduces independence andcauses loss of role and self-esteem. It is hardly surprising that clinicaldepression in severe COPD is common All health professionals caring for COPDpatients need to be alert to the signs ofdepression.Diana Hart 201334

Family and relationshipproblems Long term illness places considerable strains onfamilies and partners. Carers often suffer from anxiety and depression.The additional domestic burden they shoulder mayproduce feelings of resentment on their part andguilt on the part of the patient. COPD affects older people and a patient’s maincarer may also be elderly and ill. COPD is a progressive, long-term and eventuallyterminal illness.Diana Hart 201335

Summary The aim of treatment should be toenable patients not simply to live withCOPD, but to have a life with it. With appropriate treatment andsupport it is possible to put qualityback into their remaining years.Diana Hart 201336

References The Burden of COPD.(2003)Report by the Thoracic Society of NewZealand.Asthma and Respiratory Foundation of New Zealand GINA-www.ginaasthma.comAsthma and Respiratory Foundation of NZ-www.asthmanz.co.nzNational Collaborating Centre for Chronic Conditions. Chronic obstructivepulmonary disease: national clinical guideline on management of chronicobstructive pulmonary disease in adults in primary and secondary care.Thorax 2004; 59 (Suppl 1): 1-232Agusti AG, Noguera A, Sauleda J, Sala E, Pous J, Busquet X . Systemiceffects of chronic obstructive pulmonary disease. European RespiratoryJournal 2003; 21(2): 347-360Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP. Prognostic value ofnutritional status in chronic obstructive pulmonary disease. AmericanJournal of Respiratory and Critical Care Medicine. 1999; 160: 1856-1861 [Diana Hart 201337

Chronic obstructive pulmonary disease: national clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004; 59 (Suppl 1): 1-232 Agusti AG, Noguera A, Sauleda J, Sala E, Pous J, Busquet X . Systemic effects of chronic obstructive pulmonary disease. European Respiratory