9.15.08 COPD


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9.15.08 COPD

  1. 1. Competencies: Medical Knowledge, Practice Based Learning Learning Objectives: After this AME the learner should be able to: 1. Properly diagnose and classify COPD from PFTs 2. Prescribe the proper medications for chronic and acute COPD 3. Properly prescribe interventions (flu/pneumo vaccine, pulm rehab, d/c smoking) for COPD Source Articles: 1. “COPD” Annals of Internal Medicine 4 March 2008; 148 (5) Key Points:  Background: o COPD is the 4th leading cause of death worldwide o Approximately 80-90% of cases of COPD are secondary to tobacco smoke o The approximate risk of clinically significant COPD among smokers is 15%  Bronchitis and Emphysema: o Chronic bronchitis is defined as at least 90 days of cough and production of sputum for 2 consecutive years o Emphysema is defined as a ‘pathologic diagnosis’ which is suggested by hyperinflation on exam or imaging o Neither chronic bronchitis nor emphysema is required to diagnose COPD  Diagnosis: o The diagnosis of COPD requires an FEV1/FVC ratio after bronchodilation of less than 0.70 o The FEV1 percentage predicted can be utilized to classify COPD as mild (>80%), moderate (50-80%), severe (30-50%) or very severe (<30%) o Consider ordering an alpha 1-antitrypsin level in patients <50 yrs presenting with COPD  Treatment: o Inhaled medications form the cornerstone of treatment for COPD, though no formulations leads to decreased rates of mortality, but rather decrease morbidity and hospitalizations o The ACP recommends that, in general, long-acting bronchodilators and inhaled steroids be reserved for those with symptoms and an FEV1 less than 60% of predicted o Therapy generally is initiated with a short-acting inhaler prn, with subsequent addition of long-acting bronchodilator and/or inhaled steroid for continued symptoms o Acute exacerbations of COPD should be treated with bronchodilators, steroids, and (likely) antibiotics, as antibiotics should be strongly considered in moderate- severe exacerbations o The only therapeutic intervention that has been shown to prolong life in hypoxemic patients with chronic obstructive pulmonary disease is supplemental oxygen therapy o All patients with moderate to severe symptomatic COPD should be offered pulmonary rehab  The BODE Index consists of measures of Body mass index, obstruction, dyspnea, and exercise, and can be utilized to determine prognosis and need for hospitalization  All patients with COPD should be encouraged to stop smoking  Patients should be offered influenza and pneumococcal vaccines AME answers are due in clinic by September 26 for credit AME 9.15.08 – 9.19.08 COPD Author: Russ Bedsole, M.D. Attending Version
  2. 2. Questions Name ________________________ 1. A 60 yo male presents for evaluation of increased shortness of breath x 2 weeks. He has a history of COPD. He has no recent hospitalizations, no recent antibiotics, no known sick contacts. He notes increased sputum production, but no change in color of sputum. He denies any fever, chills, and increase in cough or wheezing. Vital signs reveal pulse of 70, RR of 18, sat of 95% on ra, which are identical to previous values when patient was at his baseline. Exam is essentially unchanged from prior exams. Based on the above, this patient has: a. A mild COPD exacerbation b. A moderate COPD exacerbation c. A severe COPD exacerbation Answer: B. Based on generally accepted criteria, the patient has a moderate COPD exacerbation. See box in article for full delineation-the three major criteria for exacerbation are: 1)worsening dyspnea 2)increase in sputum volume 3)increase in sputum purulence 2. What are the most likely bacterial pathogens in this case? (more than one answer) a. Haemophilus influenza b. Streptococcus pneumoniae c. Moraxella catarrhalis d. Staphylococcus aureus e. Pseudomonas aeruginosa f. Klebsiella pneumoniae Answer: A, B, and C. The most common bacterial pathogens in a COPD exacerbation are the first 3. 3. A randomized, double-blind trial demonstrated that the combination of salmeterol and fluticasone in patients with an FEV1 of less than 60% predicted, (compared to placebo, salmeterol alone, or fluticasone alone), demonstrated what? a. No effect on COPD exacerbations b. Decreased mortality c. Decrease in COPD exacerbations d. Increase in hospitalizations Answer: C. The study in question demonstrated a decrease in moderate-severe COPD exacerbations, with no effect on mortality. 4. You are on the medicine consult service, and are asked to see a patient with a history of moderate COPD on POD #0 s/p total knee replacement. What recommendations can you make to the orthopedic service as regards the patient’s
  3. 3. COPD which have been clearly shown to reduce post-op pulmonary complications? (more than 1 answer) a. Nasogastric tube b. Incentive spirometry c. Early ambulation Answer: B and C. These interventions have been shown to reduce rates of pneumonia, atelectasis, et al. 5. Ms. Jones is a 65 yo patient with severe COPD, with cont symptoms despite pulm rehab. Chest ct reveals bilateral emphysema. Post bronchodilator total lung capacity and residual volume are greater than 150% and 100% of predicted, respectively. FEV1 is 18% of predicted. Room air PaO2 and PaCO2 are 55 mmHg predicted, respectively. Does she meet the criteria for total lung reduction surgery? Answer: The patient does NOT meet the criteria for lung reductions surgery, as her FEV1 is less than 20% of predicted. In general, lung volume reduction surgery does not improve survival. 6. Please review the Figure on page 6 for a suggested approach to COPD treatment. 7. Bonus Question: Dr. Richard Light, the author of ‘Light’s criteria’ for pleural effusions, is a professor of medicine at what institution? Answer: Vanderbilt University
  4. 4. MKSAP Answers: 1. C Upper abdominal and thoracic surgeries pose the greatest risk to patients with obstructive lung disease. Anesthesia- and narcotic-induced respiratory depression adds to the risk. In general, the farther the surgical site is from the diaphragm, the lower the surgical risk to patients with obstructive lung disease. Ophthalmologic procedures have a very low mortality rate. Short endoscopic procedures, especially with the use of local anesthesia pose a reasonably low risk. 2. C This patient's physical findings suggest pulmonary hypertension and cor pulmonale. Even though his PaO2 is greater than 60 mm Hg while he is awake, he may have nocturnal oxygen desaturation that is responsible for pulmonary hypertension. Pulse oximetry could document the presence of nocturnal hypoxemia. A full polysomnography is useful if sleep staging is required to document rapid eye movement (REM) sleep– related oxygen desaturation. Supplemental oxygen would be appropriate if marked nocturnal hypoxemia is documented. Nocturnal mechanical ventilation would not be indicated unless nocturnal hypoventilation is present. A phlebotomy is not likely to improve symptoms at this modest level of polycythemia. Adding ipratropium bromide is unlikely to reverse the nocturnal hypoxemia associated with COPD. 3. B Ciprofloxacin and other quinolones inhibit hepatic metabolism of theophylline and can cause a clinically important increase in serum theophylline levels. Elevated serum theophylline levels commonly cause nausea or vomiting and occasionally seizures. Because the therapeutic-to-toxic window is narrow for theophylline and many agents interact with this drug, it is necessary to exercise caution when adding a new medication to the regimens of patients already taking theophylline. Ciprofloxacin can cause nausea but, by itself, is not known to cause syncope, except by precipitating anaphylaxis. Albuterol, lisinopril, oxygen, and ipratropium bromide do not significantly interact with theophylline. 4. D The only therapeutic intervention that has been shown to prolong life in hypoxemic patients with chronic obstructive pulmonary disease is supplemental oxygen therapy. Two nonpharmacologic interventions have also been shown to prolong life for patients with chronic airflow obstruction: smoking cessation and lung-volume-reduction surgery in carefully selected patients. 5. A Pulmonary rehabilitation is indicated for patients with chronic respiratory impairment who, despite optimal medical management, are dyspneic, have reduced exercise tolerance, or experience a restriction in activities. Symptoms, disabilities, and handicaps, rather than the severity of lung impairment, dictate the need for pulmonary rehabilitation. Although pulmonary rehabilitation may improve symptoms and exercise tolerance, often there is no improvement in pulmonary function. 6. B Immunization with the influenza and pneumococcal vaccines is important to prevent infectious respiratory complications. Although the vaccines are not entirely protective,
  5. 5. they are likely to benefit patients with emphysema. This patient should continue her social activities and continue with the rehabilitation program to maintain her strength and conditioning. There is no evidence that prophylactic antibiotic use or wearing a surgical mask will prevent colds or pneumonia.