Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: special considerations

Chronic obstructive pulmonary disease (COPD) and older age are known to be independent risk factors for severe perioperative adverse outcomes after surgery. A basic understanding of the disease, careful preoperative evaluation and preparation of the patient, as well as a tailored anaesthetic management plan might help to decrease complications in this patient population. Aging affects the pharmacokinetics and pharmacodynamics of almost all drugs and therefore the dosage must be adapted in older patients. The type of anaesthesia (general versus regional anaesthesia) has no substantial effect on perioperative morbidity and mortality. Most patients, even with severe COPD, tolerate general anaesthesia without major problems. One important goal of the anaesthetic management is to prevent reflex-induced bronchoconstriction, which can be accomplished by the use of volatile anaesthetics. Early recovery can be facilitated by the use of short-acting drugs, such as propofol and the new opioid remifentanil. Judicious use of neuromuscular blocking agents is necessary because of the risk of residual paralysis, and those agents associated with histamine liberation should be avoided. Ventilation requires long expiration times to avoid air trapping, and hyperinflation to avoid the possible threat of pneumothorax and a decrease in cardiac output. For postoperative analgesia, a balanced regimen consisting of regional analgesia with local anaesthetics and NSAIDs should be preferred. This will enhance analgesia and reduce opioid toxicity, which is important in patients with COPD, where respiratory depression is especially dangerous.     

Indacaterol: in chronic obstructive pulmonary disease

Indacaterol is a long-acting β?-adrenoceptor agonist that is available in the EU for the maintenance treatment of airflow obstruction in adult patients with chronic obstructive pulmonary disease (COPD). Indacaterol has a 24-hour bronchodilatory effect, which allows for once-daily administration. The onset of bronchodilation after inhalation of indacaterol is fast, with significant improvements versus placebo seen 5 minutes after inhalation. In four large (n?>?400), randomized, double-blind, placebo-controlled, multicentre phase III trials, patients with COPD who received indacaterol 150 or 300?μg once daily had a significantly higher mean trough forced expiratory volume in 1 second (FEV?) than placebo recipients after 12 weeks. Trough FEV? differences between indacaterol and placebo recipients were 130-180?mL and exceeded the clinically relevant threshold of 120?mL in all trials. Furthermore, indacaterol recipients had significantly higher mean trough FEV? values after 12 weeks than patients who received formoterol, salmeterol or open-label tiotropium. COPD exacerbations and symptoms, and health-related quality of life were also significantly improved for indacaterol versus placebo recipients in some studies. Indacaterol was generally well tolerated by adults with moderate to severe COPD.     

Use of beta-adrenoceptor antagonists in older patients with chronic obstructive pulmonary disease and cardiovascular co-morbidity: safety issues

The incidence of and mortality from both chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) increase with age. In addition, the average age of patients with COPD and CVD is also increasing as a result of improvements in both pharmacological and non-pharmacological treatments. Coronary artery disease is a compelling indication for beta-adrenoceptor antagonist use in a population in whom beta-adrenoceptor antagonism is often viewed as contraindicated. beta-Adrenoceptor antagonists have been proven to improve cardiovascular morbidity and mortality but have been under-utilized in patients with COPD with concomitant CVD because of a fear of bronchoconstriction and adverse effects, particularly in the elderly. The advanced age of patients with COPD and CVD, along with the sheer number of patients with these diseases, necessitates that clinicians understand the treatment of these co-morbidities using seemingly conflicting therapy in the form of beta-adrenoceptor agonists and antagonists.We review changes in the pharmacokinetics and pharmacodynamics of beta-adrenoceptor antagonists in the elderly, the role of beta-adrenoceptor antagonists in CVD and the literature regarding the safety and mortality benefits of beta-adrenoceptor antagonists in elderly patients with COPD and concomitant CVD. We conclude that cardioselective beta-adrenoceptor antagonists appear to be safe to use in elderly male patients with mild-to-moderate COPD who have a compelling indication for beta-adrenoceptor antagonist therapy. Data in female patients are very limited. Nonselective beta-adrenoceptor antagonists should be avoided in general, except in patients with heart failure who might benefit significantly from the use of carvedilol. beta-Adrenoceptor antagonists have been shown to improve mortality in older patients with coexisting CVD and COPD.     

Chronic obstructive pulmonary disease: role of bacteria and guide to antibacterial selection in the older patient

Chronic obstructive pulmonary disease (COPD) is a common problem in the elderly. The disease is characterised by intermittent worsening of symptoms and these episodes are called acute exacerbations. The best estimate, based on several lines of evidence, is that approximately half of all exacerbations are caused by bacteria. These lines of evidence include studies of lower respiratory tract bacteriology during exacerbations, correlation of airways' inflammation with results of sputum cultures during exacerbations, analysis of immune responses to bacterial pathogens, and the observation in randomised, prospective, placebo-controlled trials that antibacterial therapy is of benefit. The most important bacterial causes of exacerbations of COPD are nontypeable Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae and Chlamydia pneumoniae. In approaching the elderly patient with an exacerbation, it is useful to consider the severity of the exacerbation based on three cardinal symptoms: increased sputum volume, increased sputum purulence and increased dyspnoea compared with baseline. Patients experiencing moderate (two symptoms) or severe (all three symptoms) exacerbations benefit from antibacterial therapy. Consideration of underlying host factors allows for a rational choice of antibacterial agent. Patients are considered to have 'simple COPD' or 'complicated COPD' based on: (i) the severity of underlying lung disease; (ii) the frequency of exacerbations; and (iii) the presence of comorbid conditions. It is proposed that patients with simple COPD are treated with doxycycline, a newer macrolide, or an extended-spectrum oral cephalosporin; and patients with complicated COPD are treated with amoxicillin/clavulanate or a fluoroquinolone. The major goals of antibacterial therapy for exacerbations of COPD are acceleration of symptom resolution and prevention of the complications of exacerbation.     

Behavioral anti-smoking trial in chronic obstructive pulmonary disease patients

Smoking causes chronic obstructive pulmonary disease (COPD), but few controlled studies have tested anti-smoking treatments in COPD. With procedures likely to attract unmotivated persons we recruited 49 quite-ill, smoking COPD patients. During one or two daily home visits for 85 days, breath carbon monoxide (CO) and self-reports of daily smoking were obtained. Patients, given quit dates and nicotine gum (2-mg pieces, up to 30 per day), were assigned randomly to three groups: Experimentals were reinforced with lottery tickets for CO <10 ppm. Cigarette Self Report (CSR) patients were reinforced for reporting no smoking that day. Controls received non-contingent payments. Each group's mean CO level fell at the quit date. Thereafter, reinforced patients maintained significantly lower CO levels than Controls. Although many more 24-h abstentions occurred in the intervention period than in baseline, few patients sustained abstinence; the groups did not differ in that regard. Outcome was predicted by decisions to throw away cigarettes when intervention began, but not by motivation scales nor Fagerstrom dependence scores. Pay schedules apparently exaggerated self-reports of reduced smoking. Although results are statistically significant, there is still no proven, practical treatment for smoking in advanced COPD.     

肺血栓栓塞症合并慢性阻塞性肺疾病患者16例临床特点分析

目的对比分析合并慢性阻塞性肺疾病(COPD)的肺血栓栓塞症(PTE)患者的临床特点。方法搜集2008年12月至2013年6月武汉市中心医院收治的16例合并COPD的PTE的住院患者的基本信息、合并疾病、吸烟指数、临床表现等数据,与无合并COPD的PTE患者26例进行比较。结果相比无合并COPD组,合并COPD的PTE患者年龄偏大[(72±8)岁与(65±12)岁,P<0.05],吸烟指数较高[(338±361)支年与(183±299)支年,P<0.05],近期卧床史较少(6%与42%,P<0.05),心率>100次/min者比例较少(31%与65%,P<0.05),二氧化碳分压(PaCO2)相对较高[(46±14)mmHg与(31±6)mmHg,P<0.01],修订版日内瓦评分较低[(3.2±2.3)分与(7.0±2.5)分,P<0.01]。结论相比无合并COPD组,合并COPD的PTE患者年龄偏大,吸烟指数较高,PTE临床可能性评分低,其临床表现与无COPD合并的患者有一定区别但不够特异,诊断需谨慎。     

Treatment options for moderate-to-very severe chronic obstructive pulmonary disease

Introduction: The appropriate drug management of COPD is still based on the use of bronchodilators, possibly associated with an anti-inflammatory agent. However, there are still fundamental questions that require clarification to optimise their use and major unmet clinical needs that must be addressed.

Areas covered: The advances obtained with the pharmacological options currently consolidated and the different approaches that are often used in an attempt to respond to unmet therapeutic needs are reviewed

Expert opinion: In view of the unsatisfactory status of current treatments for COPD, there is an urgent need for alternative and more effective therapeutic approaches that will help to relieve patient symptoms and affect the natural course of COPD, inhibiting chronic inflammation and reversing the disease process or preventing its progression. However, new pharmacologic options have proved difficult to develop. Therefore, it is mandatory to optimize the use of the treatment options at our disposal. However, there are still fundamental questions regarding their use, including the step-up and step-down pharmacological approach, that require clarification to optimise the use of these drugs. It is likely that phenotyping COPD patients would help in identifying the right treatment for each COPD patient and improve the effectiveness of therapies.     

Inhaled corticosteroids in chronic obstructive pulmonary disease: a review

Importance of the field: Chronic obstructive pulmonary disease (COPD) is a disease characterized by chronic airflow obstruction and a progressive lung function decline. Although widely used, the efficacy of inhaled corticosteroids (ICS) in the treatment of COPD remains a matter of debate.

Areas covered in this review: This article reviews the evidence about the effects of inhaled corticosteroids in the treatment of COPD.

What the reader will gain: Short-term treatment with ICS improves lung function and quality of life; in addition, several studies with longer follow-up have shown less decline over time in quality of life, and fewer exacerbations. By contrast, long-term studies have been unable to show substantial improvement in the decline of lung function in COPD. Based on these findings, it was concluded that the use of ICS did not influence the natural course of COPD. However, this conclusion has been challenged by two subsequent studies, TORCH and GLUCOLD, which both showed a reduction in lung-function decline over time with the use of ICS. These two studies indicate that ICS might indeed influence the natural course of the disease, at least in a subgroup of COPD patients.

Take home message: Further studies are needed to identify which individuals have a favorable short- and long-term response to ICS treatment.     

Roflumilast in patients with advanced chronic obstructive pulmonary disease: towards a better-targeted use

Introduction: For patients with chronic obstructive pulmonary disease (COPD), one of the main goals in its management is to reduce the number of disease exacerbations. Roflumilast is an anti-inflammatory compound used in patients with advanced COPD and chronic bronchitis in order to fulfill this objective. However, this is not always easily achieved due to the heterogeneity of the population. Clinical trial data can allow more in-depth analysis in order to identify predictors for maximal efficacy in different patient populations.

Areas covered: A post hoc pooled data analysis derived from two large-scale randomized controlled trials helped to better define the disease subsets in which roflumilast would exert the maximal therapeutic effect. These are represented by patients with prior hospitalizations for COPD exacerbations and by patients with higher values for eosinophil blood count. This analysis is the focus of our key paper evaluation.

Expert opinion: This pooled data analysis suggests that a phenotype/endotype guided therapy has the potential to be impactful on overall survival by reducing the number of exacerbations and increase the life span of patients.     

Treatment of Chlamydia pneumoniae infection and chronic obstructive pulmonary disease

Chronic obstructive lung disease (COPD) is a general term for chronic, irreversible lung disease that combines qualities of emphysema and chronic bronchitis. The standard definition of chronic bronchitis is a productive cough for three months per year (for at least two consecutive years) without an underlying aetiology. Acute exacerbation of chronic bronchitis (AECB) represents a common complaint that leads patients to seek medical attention. COPD and AECB are directly responsible for the overuse of antibiotics in the developed world. Fifty per cent of exacerbations have either viral or non-infectious origin. For this reason, antibiotic use remains controversial. Among other bacteria, Chlamydia pneumoniae is responsible for 4 - 16% of AECB in hospitalised or out-patients, although among smokers and people using steroids, the incidence is 34%. C. pneumoniae may either be the sole causative agent or a co-agent in AECB. This paper reviews the management of COPD/AECB with respect to antibiotic use. Diagnosis and antimicrobial therapy relevant to Chlamydia in the management of AECB are also evaluated in this review.     

Treatment of Chlamydia pneumoniae infection and chronic obstructive pulmonary disease

Chronic obstructive lung disease (COPD) is a general term for chronic, irreversible lung disease that combines qualities of emphysema and chronic bronchitis. The standard definition of chronic bronchitis is a productive cough for three months per year (for at least two consecutive years) without an underlying aetiology. Acute exacerbation of chronic bronchitis (AECB) represents a common complaint that leads patients to seek medical attention. COPD and AECB are directly responsible for the overuse of antibiotics in the developed world. Fifty per cent of exacerbations have either viral or non-infectious origin. For this reason, antibiotic use remains controversial. Among other bacteria, Chlamydia pneumoniae is responsible for 4 – 16% of AECB in hospitalised or out-patients, although among smokers and people using steroids, the incidence is 34%. C. pneumoniae may either be the sole causative agent or a co-agent in AECB. This paper reviews the management of COPD/AECB with respect to antibiotic use. Diagnosis and antimicrobial therapy relevant to Chlamydia in the management of AECB are also evaluated in this review.     

Procaterol metered aerosol in patients with chronic obstructive pulmonary disease

The activity and tolerability of procaterol, a recently introduced beta 2-adrenergic drug, were evaluated in comparison with fenoterol and a placebo in a single blind, cross-over study, using a metered aerosol formulation. Twelve patients suffering from chronic obstructive pulmonary disease with reversible bronchial obstruction were enrolled. Before and 30, 120, 240, 360, 480 min after drug administration, forced vital capacity (FVC), forced expiratory volume at the first second, forced expiratory flow at 25-75% and 75-85% respectively of the FVC, thoracic gas volume and the specific airways conductance were calculated. Procaterol 20 mcg showed a significant bronchodilating activity as well as fenoterol 400 mcg. This activity was already significant within 30 min, achieved its maximum after two hours and lasted more than eight hours. Side-effects were complained of by 41% of patients treated with procaterol and by 50% treated with fenoterol; procaterol showed less cardiovascular effects than fenoterol.     

Peripapillary choroidal thickness in patients with chronic obstructive pulmonary disease

Objective: To evaluate the peripapillary choroidal thickness of patients with chronic obstructive pulmonary disease (COPD) via enhanced depth imaging optical coherence tomography (EDI-OCT).

Materials and methods: A total of 80 patients with COPD (80 eyes) and 50 control subjects (50 eyes) were enrolled. Choroidal scans and the retinal nerve fiber layer (RNFL) thickness were obtained for all eyes using OCT.

Results: The average peripapillary choroidal thickness measurements of the COPD group (147.58?±?53.53?μm) were lower than the control group (160.84?±?44.73?μm) (p?=?0.068). Inferior segment thicknesses were significantly thinner than the other segments (p?<?0.05). Subfoveal choroidal thickness and RNFL thickness measurements of the COPD group were also lower than those of the control group (p?=?0.111).

Conclusion: Hypoxia in COPD seems to affect the choroidal thickness. Thinning of the choroid may be attributed to increased vascular resistance and reduced blood flow in patients with COPD. The possible effects of the disease to the eye may be clarified through the role of the choroidal vasculature in the blood supply of the anterior optic nerve head.     

慢性阻塞性肺疾病患者的老年综合征调查

目的探讨稳定期老年慢性阻塞性肺疾病(COPD)患者老年综合征的罹患情况。方法对选取我院老年医学科门诊2015年10月至2016年12月就诊的100例年龄≥65岁稳定期老年COPD患者进行老年综合评估,评估患者共患慢病、营养风险、情绪、认知、睡眠障碍、跌倒风险、日常生活能力、6分钟步行距离(6MWD)等。结果入组患者平均年龄(76±5)岁,共患慢病0～10种,平均患老年综合征数3.8±1.5,55%存在多重用药,47%存在日常生活能力下降,68%存在工具性日常生活能力下降,营养不良及风险、情绪障碍、认知损害、睡眠障碍的发生率分别为55%,52%,40%和51%。共患慢病组,营养不良发生率(61%与35%)、情绪障碍发生率(58%与30%)、认知损害发生率(44%与26%)、睡眠障碍发生率(55%与39%)和跌倒高风险发生率(35%与17%)均高于无共患慢病组,且差异均有统计学意义(P<0.05);共患慢病组6MWD较无共患慢病组[(329±59)m与(420±62)m]更短,差异有统计学意义(P<0.05)。结论老年COPD患者营养不良、情绪障碍、睡眠障碍、认知损害等老年综合征发生率高,日常生活及活动能力下降,需要进行老年综合评估及个体化管理。     

肺功能改善的临床探讨

目的 探讨呼吸康复训练和常规治疗对改善慢性阻塞性肺疾病(COPD)患者肺功能的效果比较.方法 选2010年6月至2011年5月我院60例COPD患者,按随机数字表法将其分为对照组和研究组,各30例.对照组予常规内科治疗并对其进行健康知识教育及一般康复训练,研究组在对照组治疗方案基础上,增加呼吸操训练.对比2组干预前后肺功能、6 min步行距离、血清白三烯、呼出气一氧化氮(FENO)的变化.结果 研究组肺功能比对照组明显改善,组间差异有统计学意义(P＜0.01);6 min步行距离明显改善,组间差异有统计学意义(P＜0.01);血清白三烯水平明显下降,组间差异有统计学意义(P＜0.01);FENO含量明显下降,组间差异有统计学意义(P＜0.01).结论 呼吸康复训练,尤其全身性呼吸操能明显改善COPD患者肺功能,提高患者的活动耐力,改善生活质量.     

Anemia in chronic obstructive pulmonary disease: a readmission prognosis factor

Abstract

Objective:

The prevalence of comorbid anemia in patients with COPD ranges from 7.5% to 34%. The aim of this study is to determine if anemia is a risk factor for readmission in COPD patients.