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Australian Journal of Pharmacy : May 2008
education COUNsELLING CA s EBOOK self-management of exacerbations and pulmonary rehabilitation. These guidelines deal mainly with the management of established disease and exacerbations. However, this is only one element of the COPD Strategy of the Australian Lung Foundation [www.lungnet. org.au] which has the long-term goals of: • primary prevention of smoking; • improving rates of smoking cessation; • early detection of airflow limitation in smokers before disablement; and • improved management of stable disease and exacerbation prevention. No medications for COPD have been shown to modify the long- term decline in lung function which is the characteristic of the disease. Drug treatment is aimed at reducing symptoms and complications. Stopping smoking and domiciliary oxygen are the only treatments shown to reduce mortality in COPD.4 The following notes offer further comments on the mangement of COPD: 1. ConfiRm diagnosis and assess seveRity COPD comprises three separate, but often interconnected, disease processes, all leading to progressive loss of lung function. These are: 1. chronic over-secretion of mucous, resulting in chronic cough and phlegm production.this may be associated with low-grade infection in the airways resulting in chronic bronchitis. 2. airway thickening and narrowing resulting in difficulty in breathing. 3. damage to the small airways within the lung, eventually causing destruction of elastic fibres and airway sacs resulting in emphysema. this restricts the ThE AUsTrALIAN jOUrNAL Of PhArmACy vOL.89 mAy 2008 78 lungs’ capacity to contract and expand and decreases the amount of lung tissues through which oxygen can enter the body.5 The diagnosis of COPD rests on the demonstration of airflow limitation which is not fully reversible. If airflow limitation is fully or substantially reversible, the patient should be treated as for asthma. Symptoms The main symptoms of COPD are breathlessness, cough and sputum production. Patients often attribute breathlessness to ageing or lack of fitness. A persistent cough, typically worse in the mornings with mucoid sputum, is common in smokers. Other common symptoms include chest tightness, wheezing and airway irritability. Acute exacerbations, usually infective, occur from time-to- time and may lead to a sharp deterioration in coping ability. Fatigue, poor appetite and weight loss are more common in advanced disease. Some physicians may describe patients as: no medications for copd have been shown to modify the long-term decline in lung function which is the characteristic of the disease. ‘Pink PufferS’—thin, anxious patients with Type 1 respiratory failure with no carbon dioxide retention and; ‘Blue BloaTerS’—large, quiet with Type 2 respiratory failure and carbon dioxide retention.6 Severity is defined according to the degree of airflow obstruction measures by forced expiratory volume in one second (FEV1 Mild disease: FEV1 ). 60–80% of age/ sex predicted—with cough, minimal dyspnoea, normal examination. Moderate disease: FEV1 40–59% of predicted with cough, breathless on moderate exertion, wheeze, hyperventilation, and reduced air entry. Severe disease: FEV1 <40% with cough, breathless on minimal exertion, signs of moderate COPD, possibility of respiratory failure and right heart failure.6 The Medical Research Council's five-point grading of functional limitation due to dyspnoea7 is: 1. ‘i only get breathless with strenuous exercise.’ 2. ‘i get short of breath when hurrying on the level or walking up a slight hill.’ 3. ‘i walk slower than most people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level.’ 4. ‘i stop for breath after walking about 100 yards or after a few minutes on the level.’ 5. ‘i am too breathless to leave the house.’ or ‘i am breathless when dressing.’ Investigations carried out by the physician will include: • spirometry checking lung function tests and arterial blood gases; • assessment of degree of reversibility with ß2 corticosteroids; • Chest X Rays to exclude other (smoking-related) pathology; and • Computed tomography 2. optimise function Therapeutics: Symptom relief: Inhaled bronchodilators (eg. salbutamol 100–200mcg, or terbutaline agonists and