Panacea Pharmacy & Medic

Asthma & Chronic Obstructive Pulmonary disease (COPD)

Topics more contain

1. Asthma-causes-and-symptoms

2. Treatment-of-asthma

3.What is Chronic obstructive pulmonary disease (COPD), causes, factors and symptoms ?

4.Treatment of mild chronic obstructive pulmonary disease (COPD).

5.Treatment of moderate chronic obstructive pulmonary disease COPD patient.

6.Treatment of severe chronic obstructive pulmonary disease ( COPD).

 

Asthma

Dfinition

Chronic inflammatory disorder of the Airways.  it involves Complex interaction between  many cell and inflammatory mediators. Inflammation can   partially or completely or reversible obstruction of the  airway.

Classification

Actually  they are  Three  types :  mild,  moderate and severe.

 patients severity may classify by determining

1, symptoms (    Short acting beta agonist use  nocturnal symptoms)

2.  Interference with normal daily activities

3, Lungs function (  spirometry to determine  FEV1  & FVC )

4, Frequency of exacerbations

Causes

  1. Allergens (  eg. Pollen,  house dust mite,  animal dander,  mould,  cockroach,  food)
  2.  occupational exposure ( eg.  chemical  irritants,  frour , wood,  textile dusts.)
  3.  viral respiratory tract infection
  4.  Exercise
  5.  Emotions ( eg,  anxiety, Stress,  hard laughter,  crying)
  6. Exposure to irritants ( eg.Strong orders,  chemicals,   fumes ) 
  7.  Environmental exposure (  weather changes,  cold air,  Sulphur dioxide,  cigarette smoke ) 
  8.  drugs like NSAID ( Aspirin,  Ibuprofen etc ), Antiadrenergic and cholinergic drugs( eg.  beta adrenergic blockers,   Botanical) 

Clinical evaluation

physical finding

Physical findings depend on the severity of the underlying exacerbation

Mild exacerbation

Symptoms
  • Breathless while walking,  speaks in sentences, Moderate   wheezing
  • FEV1 or FVC< 70 % of normal 
  •  Arterial pH :Normal or increase
  • PaO2:Normal or decrease
  • PaCO2: Normal or decrease

Moderate exacerbation

Symptoms
  • Dyspnea while at rest, in phrases, Loud wheezing throughout expiration
  • FEV1 / FVC:<40 % of normal (40-70)%
  • Peak expiratory flow rate (PEFR)< 50% of normal
  •  Arterial pH :Increase
  • paO2: <70 mm Hg
  • paCO2:> 30 mm Hg

Severe  exacerbation

Symptoms
  • Breathless while at rest, 
  • Speaks in words loud wheezing,
  • Coughing
  • difficulty speaking,
  • Accessory chest muscle use and chest hyperinflation
  • FEV1 / FVC; <25% of normal 
  • Peak expiratory flow rate (PEFR)< 33% of normal
  • Arterial pH ; Normal or decrease
  • paO2: < 60 mm Hg
  • paCO2; > 42 mm Hg
  • Respiratory failure
Symptoms
  • Severe respiratory distress,
  • Confusion lethargy, 
  • cyanosis
  • disappearance of breath sound and pulsus paradoxus > 12 mm Hg
  • FEV1 / FVC; <25% of normal 
  • Arterial pH ; Extremely decrease
  • PaO2:  Decrease
  • PaCO2: Extremely increases.

Acute exacerbation 

common findings are 

  • Shortness of breath
  • Wheezing
  • Chest tightness
  • Cough
  • Tachypnea  and tachycardia
  • Pulsus paradoxus

Diagnostic test results

A. Pulmonary function test

Determine the degree of airway obstruction  recommended spirometry in all asthma patients greater than 5 years old. Breathing test Include spirometry and Speak  flow meter testing,

 

  1. Forced expiratory volume in 1 second ( FEV1 ) and  forced vital capacity (FVC) both decrease during an  acute exacerbation.
  2. Residual volume (RV) and total lung capacity (TLC) may increase .
  3. Peak expiratory flow rate (PEFR) can be used to monitor or control of asthma

B. Blood analysis

White blood cell count it may be increased due to acute exacerbation

C . Arterial blood gas measurement

1. Early stage PaCO2  decrease

              Gradually PaCO2  increase Due to  acute exacerbation

D.  Electrocardiogram (ECG)  may show sinus tachycardia
E. Chest radiograph may be normal or cloud detect accompanying Pneumothorax,  atelectasis  or pneumonia.

 sign of respiratory distress include

  •  inability to East akin sentence or ambulate owing to dyspnea,
  • Declining mental status
  • PEFR < 50%  of predicted
  •  Cyanosis
  •  suprasternal retractions,
  •  absence of respiratory sound
  •  increasing paco2
  •  unable to sleep for extended time because of shortness of breath

 Note:  patient with potentially fatal asthma should be quickly  identify and aggressively managed Need to hospitalization.

Prevention and treatment of asthma

Exercise-induced bronchospasm (EIB )

You can prevent exacerbation Due to exercise By using medication .

1.1, Short acting beta agonist ( eg. Albuterol) Should be administered 15 minutes before exercise.

1.2,  long acting  beta agonist and formoterol should be administered 30 to 60 mins  before exercise.

Concurrent disease

Allergic rhinitis sinusitis and Gastroesophageal Reflux disease (GERD),  vocal cord dysfunction and obstructive sleep apnea  frequently coexist with asthma. It should be better to management of this concurrent disease by medication with Asthma treatment.

2.1. For Gastroesophageal Reflux disease  Medication should be use  such as PPI (eg. esomeprazol, Pantoprazol) or H2 receptor antagonist (eg, Famotidin)

2.2. For allergic rhinitis medication should be used such as antihistamine ( eg. rupatidin. cetirizine)

Treatment for pre asthma patient

 it is better to   prevent Asma as early diagnosis  medication should be used  Corticosteroid  Such as

Flunisolide

Dose:  For children 1000-1250 Microgram 3  times a day For 2 months  then 1-2 times a day for 3 months. 

For adults 1000-2000 Microgram 3  times a day For 2 months  then 1-2 times a day for 3 months.

Fluticasone

Dose as MDI( metered dose inhaler):  for children 176-440 Microgram 3  times a day For 2 months  then 1-2 times a day for 3 months.

 For adults 264-660 Microgram 3  times a day For 2 months  then 1-2 times a day for 3 months.

   Dose as DPII( Dry powder inhaler):  for children 200-400 Microgram 3  times a day For 2 months  then 1-2 times a day for 3 months.

 For adults 300-600 Microgram 3  times a day For 2 months  then 1-2 times a day for 3 months.

Note: It should be concern about diabetics patient for using of steroid. It will need better for dose reduction.

Treatment for mild asthma

 Medication 1:

1.1.Inhaled short acting β2  agonist (eg Albuterol)

Dose:

For pediatric

NEB (nebulizer) (0.5%)(5µg/ml):  Inhales 20 minutes three times a day 

MDI (Metered dose)(0.09 mg/puff):  4-8 puffs 6 times a day .

Oral dose: 0.3-0.6 mg/kg/day (maximum 8 mg/day)

For adult

NEB (nebulizer) (0.5%)(2.5-5 mg):  Inhales 20 minutes three times a day 

MDI (Metered dose)(0.09 mg/puff):  4-8 puffs 6 times a day .

Oral dose: 40 mg for 12 hours interval

                     Or

1.1.Inhaled lognt acting β2  agonist (eg .Formoterol)

Dose:

For children greater than 5 years old

DPI (12 mg/cap for inhalation): 1 capsul for 2 times a day

For adult: 1 capsule for 2 times a day.

                            Or

1.1. eg. Salmeterol

  For Children greater than 4 years old

MDI (0.025 mg/puff):  1-4 puffs 2 times a day .

DPI ( 0.05 mg/Inhalation):  1 inhalation 2 times a day

For adult

MDI (0.025 mg/puff):  2-4 puffs 2 times a day .

DPI ( 0.05 mg/Inhalation):  1 inhalation 2 times a day

                                      Or

Combination (short acting β2 agonist eg Albuterol + long acting anticholinergic  eg. Ipratropium bromide)

Dose

NEB (Albuterol  2.5 ml + Ipratropium 0.5 ml ) with 2.5 ml 0.9% NaCl solution: Nebulizing 20 min for 3 times   daily.

MDI (0.1 g + 0.02 mg): 2 puffs 4 times daily.

  1.2 Anticholinergic ( eg. Ipratropium bromide)

Dose

MDI (500 µg): 2 inhalation 4 times a day

1.3 Steroid ( eg. Budesonaide)

DPI (200 µg/ Inhalation):  Inhalation or nebulization for 3-4 times a day.

Dose

Child: 400-800 µg

Adult: 600-1200 µg

                 Or

1.3 Steroid ( eg. Fluticasone)

MDI ( 220 µg/ Puff): 1 – 2 puffs  2-3 times daily

Dose

Child: 176-440 µg

Adult: 264-660 µg

Or

DPI (250 µg/ Inhalation):  Inhalation or nebulization for 2-3 times a day.

Dose

Child: 200-400 µg

Adult: 300-600 µg

Or

1.3 Steroid ( eg. Prednisolone)

Child: 5-20 mg/day

Adult: 10-60 mg/day

Note: It should be concern about diabetics patient for using of steroid. It will need better for dose reduction.

1.4 Leukotriene Modifiers ( e.g. Montelukast)

Dose

Child < 4 years : 4 mg/ daily single dose

Child > 4 years : 5 mg/ daily single dose

Adult:  10 mg/ daily single dose

1.5. Theophylline

 May be consider if β-agonist and  corticosteroid fail to control an acute asthma exacerbation.

Dose

Child > 2 years : 10 mg/ kg/daily 2-3 dose( maximum 300 mg/day) Adult:  100-400 mg/ daily 2-3 dose( maximum 800 mg/day

Chronic obstructive pulmonary disease (COPD)

COPD

Chronic obstructive pulmonary disease (COPD) is a state characterized by airflow limitation owing to chronic bronchitis or emphysema. It is progressive disease and not fully reversible.

Formation types of COPD??

There are two types

  1. Chronic bronchitis: It is characterized by excessive mucus production by the tracheobronchial tree. That may airway obstruction as a result of edema and bronchial inflammation. COPD patient has a cough producing more than 30 ml of sputum in 24 hours for at least 3 months of the year for 2 consecutive years.
  2. Emphysema: It is characterized by permanent alveolar enlargement distal to the terminal bronchioles and destructive changes of the alveolar walls. Alveolar surface area losses and causes airway limitation.

Note: Comorbidities such as CHF, CAD, Stroke, DM, and Depression are common in COPD patients.

Causes

  1. Cigarette smoking
  2. α 1- antitrypsin ( AAT) deficiency.
  3. Expose to irritants such as sulfur dioxide, polluted partials, noxious gas, organic or inorganic dust or combustible fuels in the home etc.
  4. A history of respiratory infection or bronchial hyper reactivity.
  5. Social, economic or hereditary factors.

Pathophysiology

  1. Chronic bronchitis

  • When respiratory tissue inflamed result in vasodilation, congestion, mucosal edema, and goblet cell hypertrophy. That triggers to produce excessive amount of mucus.
  • Tissue structure become changes like increase smooth muscle, cartilage atrophy, infiltration of neutrophils and other cell and impairment of cilia.
  • Airway become blocked by thick, tenacious mucus secretion which trigger a productive cough.
  • Alveoli become infection by various bacteria or virus like streptococcus pneumonia, Haemophilus influenza, Moraxella cattarrhalts, Staphylococcus aureus and Pseudomonas aeruginosa species. Recurrent lung infection reduce ciliary and phagocytic activity, increase mucus accumulation, weaken body’s defense and destroy further small bronchioles.
  • Overall impaired gas exchange decrease blood PaO2 increase PaCO2 may result exertional dyspnea and hypercapnia.

       2. Emphysema

  • From the bronchitis breakdown of the bronchioles, alveolar walls and connective tissue finally resulted alveoli merge, the number of alveoli diminishes and reduce the alveolar elasticity which entrapped air.
  • Finally increase lung volume decrease blood PaO2 increase PaCO2 causes exertional dyspnea and hypercapnia.

 

Clinical evaluation

  1. Chronic bronchitis :
  • Symptoms are onset after the age of 45 years.
  • Productive cough in winter then progresses to years round.
  • Exertional dyspnea.
  • Obesity, rhonchi, wheezes and prolonged expiration.
  • Right ventricular failure, peripheral edema, hepatomegaly, and cardiomegaly.
          2. Emphysema
  • Symptoms are onset after the age of 55 years.
  • Exertional dyspnea. It may be progressive, severe, constant than Chronic bronchitis
  • Weight loss
  • Tachypnea
  • Pursed-lips-breathing
  • Prolonged expiration
  • Diaphragmatic excursion
  • Diminished breath sound

 

Diagnostic

Normally COPD common finding

  • Cough
  • Dyspnea
  • Sputum production
  • FEV1/FVC < 70%

Chronic bronchitis diagnostic

Physical finding

  1. Dyspnea
  2. Coughing, thick purulent or mucopurulent sputum that may yellow color, white, green or gray in color.

Blood test

  1. Polycythemia
  2. WBC count may increase due to infection.
  3. Arterial blood gas studies

!. Decrease PaO2 level ( 45 to 60 mm Hg)

!!. Increase PaCO2 level ( 50 to 60 mm Hg)

     4. Hypercapnia

Spirometer test

  1. FEV1/FVC < .08
  2. Increase residual lung volume
  3. Decrease vital capacity (VC)
  4. Decrease FEV1

Chest Radiograph (X-Ray)

  1. Lung hyperinflation
  2. A barrel chest
  3. Increase bronchovascular marking

Heart function test

  1. Right ventricular hypertrophy
  2. Tachycardia

 

Emphysema diagnostic

Physical finding

  1. Dyspnea
  2. Scanty sputum that is clear or mucoid.

Blood test

  1. Polycythemia
  2. WBC count may increase due to infection but infection is less common.
  3. Arterial blood gas studies

!. Decrease PaO2 level ( 65 to 75 mm Hg) or may not change.

!!. Increase PaCO2 level ( 50 to 60 mm Hg)

        4. Hypercapnia

Spirometer test

  1. FEV1/FVC < .08
  2. Increase residual lung volume and TLC
  3. Decrease vital capacity (VC)
  4. Decrease FEV1

Chest Radiograph (X-Ray)

  1. Lung hyperinflation
  2. Flattened diaphragm
  3. Vertical heart
  4. Enlarged anteroposterior chest diameter
  5. Decreased vascular marking

 

Heart function test

  1. Right ventricular hypertrophy
  2. Tachycardia

Treatment of COPD

Pharmacological and non-pharmacological both treatments are required simultaneously to get better effect from COPD disease condition.

Pharmacological treatment

Note : All  medication of COPD are only for adult person who are above 16 years old.

The pharmacological treatment are depend on three different stage of COPD patient according to their severity.

Basically COPD stage are three types according to severity. They are –

  1. Mild COPD
  2. Moderate COPD
  3. Sever COPD

Treatment for Mild COPD

Symptoms

Physical finding

  • Cough may produce or not
  • Dyspnea may occurred or not
  • Sputum production or not

 

Blood test

  1. Polycythemia
  2. WBC count may increase due to infection.
  3. Arterial blood gas studies

!. PaO2 level may decrease or not ( 45 to 60 mm Hg)

!!. PaCO2 level may Increase or not ( 30 to 60 mm Hg)

!!!. Decrease arterial pH

Spirometer test

  1. FEV1/FVC < 70%
  2. Increase residual lung volume
  3. Decrease vital capacity (VC)
  4. Decrease FEV1 <80%

Heart function test

a.Tachycardia may shown

Medication

      1.1.    Short acting β2 agonist

Eg. Albuterol

Dose

Nebulization: 2.5 mg with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

DPI:  1 to 2 inhalation each contain 180 mcq orally every 4 to 6 hours.

 Or

1.2. Short acting anticholinergic

Eg. Ipratropium

Dose

Nebulization: 500 mcg with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

MDI: One or two puff (20 mcg/puff) three or four times a day.

Or

     1.3. Combination of long acting β2 agonist and Short acting anticholinergic.

Eg. Salbutamol + Ipratropium

       Dose

Nebulization: Salbutamol + Ipratropium (2.5 mg + 500 mcg ) with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

MDI:  One or two puff {Salbutamol + Ipratropium (20 mcg + 100 mcg )} two or three  times a day.

Indication:

You can take any one of three above medication for 5 to 7 days or when exacerbation occurred. You should take or one or two puff as MDI 30 min before starting exercise.

Note: I suggest taking 1.3 no medicine of above should better choice of you.

Treatment for Moderate COPD

Symptoms

Physical finding

 

  • Cough may produce or not.
  • Dyspnea occurred slightly.
  • Sputum production or not.
  • FEV1/FVC < 70%, It may be reduced to 50%.
  • FEV1 < 50%.
  • Decrees concentration

Blood test

  1. Polycythemia
  2. WBC count may increase due to infection.
  3. Arterial blood gas studies

!. PaO2 level may decrease or not ( 45 to 60 mm Hg)

!!. PaCO2 level may Increase or not ( 50 to 60 mm Hg)

Spirometer test

  1. FEV1/FVC < 70% It may be near to 50%
  2. Increase residual lung volume
  3. Decrease vital capacity (VC)
  4. Decrease FEV1 <80% or near to 50%

 

Heart function test

a.Tachycardia may shown

Medication

2.1.Short acting β2 agonist

Eg. Albuterol

Dose

Nebulization: 2.5 mg with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

DPI:  1 to 2 inhalation each contain 180 mcq orally every 4 to 6 hours.

 Or

2.2. Short acting anticholinergic

Eg. Ipratropium

Dose

Nebulization: 500 mcg with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

MDI: One or two puff (20 mcg/puff) three or four times a day.

Or

       2.3. Combination of long acting β2 agonist and Short acting anticholinergic.

Eg. Salbutamol + Ipratropium

       Dose

Nebulization: Salbutamol + Ipratropium (2.5 mg + 500 mcg ) with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

MDI:  One or two puff {Salbutamol + Ipratropium (20 mcg + 100 mcg )} two or three  times a day.

Indication:

You can take any one of three above medication for 5 to 7 days or when exacerbation occurred. You should take or one or two puff as MDI 30 min before starting exercise.

Note: I suggest taking 2 .3 no medicine of above should better choice of you.

 

If fast line medicine does not work properly you should take second line medicine.

 

Second line medication:

3.1. Combination of short acting β-agonist (levalbuterol) and long acting anticholinergic (tiotropium).

  a. Levalbuterol

Dose for adult

MDI: 2 puffs every 4 to 6 hours as needed.

Nebulization: 0.63 to 1.25 mg with 3 ml 0.9N Nacl every 4 to 6 hours as needed up to 3 doses per 24 hours.

 b. Tiotropium

Dose for adult

MDI: 2 puffs per puff contain 1.25 mcg once a day as needed.

Nebulization: 1.25 to 2.5 mcg with 3 ml 0.9N Nacl once per 24 hours.

Note : If combination dose is not available You must take medication a and b individually, I nebulization combination solution may use. Nebulization should take 20 minutes interval for 1 hour and better to take when exacerbation or may take two times a day.

Many of the country like Bangladesh this combination or individual medicine is not available. In this case I recommended another combination of medicine that are available. You should use this combination when fast combination or individual medicine is not available.

Medication:

3.2. combination of Salmeterol + Fluticasone Propionate

I suggest as MDI

Doses: {Salmeterol ( 25 mcg) + Fluticasone Propionate(250 mcg)} per puff.

Tow puffs two times a day.

3.3. Theophylline

Dose:

400 mg tablet form twice daily for 15 days to 1 month.

 

You should use combination 3.1 with 3.3 medications simultaneously.

If use combination 3.1 with 3.3 medications simultaneously and

It could not work well you should add 3.2 medication with 3.1 & 3.3 medicine.

When your lung is infected by various bacteria or virus you should use antibiotics with above medicine.

It is better to use antibiotics by screening test of various microorganism resistances.  

Without this screening test you may used antibiotics like –

            3.4. Azithromycin

Dose

Tablet form of Azithromycin 500 mg once daily for 5 to 7 days.

If your first antibiotics Azithromycin does not work well you should add 2nd antibiotics like levofloxacin with azithromycin.

          3.5. Levofloxacin

Dose:

Tablet form levofloxacin 500 mg once daily for 7 days.

How can you understand that you should need to take antibiotics???

Physical finding:

  • Cough may produce.
  • Dyspnea occurred slightly.
  • Sputum production.
  • Decrees concentration

Blood test

  • WBC count may increase due to infection.

 

You may also added more medicine when your disease condition is very worse.

3.6.  Steroid ( eg. Prednisolone)

Dose

Tablet form of prednisolone 20 mg once or twice a daily.

Adult: 10-60 mg/day

Note: It should be concern about diabetics patient for using of steroid. It will need better for dose reduction.

3.7. Leukotriene Modifiers ( e.g. Montelukast)

Dose

Adult:  10 mg/ daily single dose

3.8. Cough exponent ( eg. Ambroxol) 

Dose

Syrup formation 10 ml each time for three times a day.

Finally it is important to ensure oxygen supply at least 12 hours per day until development the dyspnea.

 

Treatment for Sever COPD

Symptoms

Physical finding

  • Cough may produce.
  • Dyspnea occurred it may sever.
  • Sputum production it may also sever.
  • FEV1/FVC < 50%, It may be reduced to 30%.
  • FEV1 < 30%.
  • Decrees concentration
  • Skin becomes yellowish color due to lacking oxygen supply in the body.
  • Bluer vision

Blood test

  • Polycythemia
  1. WBC count may increase due to infection.
  2. Arterial blood gas studies

!. PaO2 level may decrease or not ( 30 to 45 mm Hg)

!!. PaCO2 level may Increase or not ( 40 to 70 mm Hg)

!!!. Decrease arterial pH seriously.

Spirometer test

  1. FEV1/FVC < 50% It may be near to 30%
  2. Increase residual lung volume
  3. Decrease vital capacity (VC)
  4. Decrease FEV1 <50% or near to 30%

 

Heart function test

a.Tachycardia may shown

Medication

4.1.Short acting β2 agonist

Eg. Albuterol

Dose

Nebulization: 2.5 mg with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

DPI:  1 to 2 inhalation each contain 180 mcq orally every 4 to 6 hours.

 Or

4.2. Short acting anticholinergic

Eg. Ipratropium

Dose

Nebulization: 500 mcg with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

MDI: One or two puff (20 mcg/puff) three or four times a day.

Or

4.3.Combination of long acting β2 agonist and Short acting anticholinergic.

Eg. Salbutamol + Ipratropium

       Dose

Nebulization: Salbutamol + Ipratropium (2.5 mg + 500 mcg ) with 3 ml 0.9N NaCl solution three to four times a day, over approximately 5 to 15 minutes by nebulizer machine.

MDI:  One or two puff {Salbutamol + Ipratropium (20 mcg + 100 mcg )} two or three  times a day.

Indication:

You can take any one of three above medication for 5 to 7 days or when exacerbation occurred. You should take or one or two puff as MDI 30 min before starting exercise.

Note: I suggest taking 4 .3 no medicine of above should better choice of you.

 

If fast line medicine does not work properly you should take second line medicine.

 

Second line medication:

5.1. Combination of short acting β-agonist (levalbuterol) and long acting anticholinergic (tiotropium).

     a. Levalbuterol

Dose for adult

MDI: 2 puffs every 4 to 6 hours as needed.

Nebulization: 0.63 to 1.25 mg with 3 ml 0.9N Nacl every 4 to 6 hours as needed up to 3 doses per 24 hours.

         b. Tiotropium

Dose for adult

MDI: 2 puffs per puff contain 1.25 mcg once a day as needed.

Nebulization: 1.25 to 2.5 mcg with 3 ml 0.9N Nacl once per 24 hours.

Note : If combination dose is not available You must take medication a and b individually, I nebulization combination solution may use. Nebulization should take 20 minutes interval for 1 hour and better to take when exacerbation or may take two times a day.

Many of the country like Bangladesh this combination or individual medicine is not available. In this case I recommended another combination of medicine that are available. You should use this combination when fast combination or individual medicine is not available.

Medication:

5.2. combination of Salmeterol + Fluticasone Propionate

I suggest as MDI

Doses: {Salmeterol ( 25 mcg) + Fluticasone Propionate(250 mcg)} per puff.

Tow puffs two times a day.

        5.3. Theophylline

Dose:

400 mg tablet form twice daily for 15 days to 1 month.

 

You should use combination 5.1 with 5.3 medications simultaneously.

If use combination 5.1 with 5.3 medications simultaneously and It could not work well you should add 5.2 medication with 5.1 & 5.3 medicine.

When your lung is infected by various bacteria or virus you should use antibiotics with above medicine.

It is better to use antibiotics by screening test of various microorganism resistances. 

Without this screening test you may used antibiotics like –

     5.4. Azithromycin

Dose:

Tablet form of Azithromycin 500 mg once daily for 5 to 7 days.

If your first antibiotics Azithromycin does not work well you should add 2nd antibiotics like levofloxacin with azithromycin.

     5.5. Levofloxacin

Dose:

Tablet form levofloxacin 500 mg once daily for 7 days.

How can you understand that you should need to take antibiotics???

Physical finding:

  • Cough may produce.
  • Dyspnea occurred slightly.
  • Sputum production.
  • Decrees concentration

Blood test

  • WBC count may increase due to infection.

You may also added more medicine when your disease condition is very worse.

5.6.  Steroid ( eg. Prednisolone)

Dose

Tablet form of prednisolone 20 mg once or twice a daily.

Adult: 10-60 mg/day

Note: It should be concern about diabetics patient for using of steroid. It will need better for dose reduction.

5.7. Leukotriene Modifiers ( e.g. Montelukast)

Dose

Adult:  10 mg/ daily single dose

5.8. Cough exponent ( eg. Ambroxol) 

Dose

Syrup formation 10 ml each time for three times a day.

Finally it is important to ensure oxygen supply at least 17 hours per day until development the dyspnea.  It is better for patient to hospitalized.

Caution

When any COPD patient use above medication you should highly cautious.

Patient should avoid  medicine who are:

  • Chronic kidney patient
  • Chronic liver disease patient
  • Heart failure patient
  • pregnant and lactation patient
Patient should partially cautious to taking medicine no 3.2,3.6  5.4,  & 5.6 of above who are:
  • strong diabetics patient
  • Mild or moderate diabetics patient not need more cautious.
Patient should partially cautious to taking medicine no 1.2,  1.3, 2.2, 2.3, 3.1, 4.2, 4.3, 5.1  & 5.2 of above who are:
  • Severe tachycardia patient like pulse rate more then 115 beat per minutes.
  • Mild or moderate tachycardia patient not need more cautious.
Patient should partially cautious to taking medicine no 3.4  & 5.4 of above who are:
  • Severe gastric, peptic or duodenum ulcer patient. 
  • Mild or moderate gastric, peptic or duodenum ulcer patient not need more cautious.
  • Sever gastric, peptic or duodenum ulcer patient may take above medicine with mucus membrane protective medicine like PPI (eg. Omeprazole) or H2 (eg. Famotidine) receptor blocker.