Management of Chronic
Airflow Obstruction
J.R. Sheller, M.D.
Allergy, Pulmonary & Critical Care
Medicine
Chronic Airflow Obstruction
• Asthma
• COPD – emphysema/chronic obstructive
bronchitis
• Bronchiectasis – cystic fibrosis
...
• 12.1 million adults ages 25 and older
reported being diagnosed with COPD; 21
million asthmatics
• Total estimated cost o...
Spirometry
Functional residual
capacity
FEV1
(%) max
Time (yrs)
8020 40
100
50
Disability
Death
FEV1
(%)
Time (yrs)
8020 40
100
50
Disability
Death
Smoking Cessation
• Counseling
– Has patient thought about stopping?
– Rehearse reasons to quit
– Offer to help
• Group th...
Bronchodilators
• Beta2 adrenergic agonists
– By metered dose inhaler
– By nebulizer
• Short acting – albuterol, terbutali...
Anticholinergics
• Ipratropium
• Tiatropium
Work best in COPD
Viral exacerbations of asthma in children
Theophylline
• Methylxanthines – adenosine antagonists,
phosphodiesterase inhibitors, induces
histone deactylase
• Narrow ...
Antiinflammatory RX
• Can improve function
• Can improve symptoms
• Uncertain if it alters natural history
• May affect st...
Inhaled Corticosteroids
• Topically active
• Delivered to the airway
• First pass liver metabolism reduces
systemic availa...
Inhaled Corticosteroids
• Theoretical:
– suppression of adrenals
– growth retardation in kids
• Known:
– oral thrush and v...
• Beclomethasone – 2 puffs QID
• Triamcinalone – 2 inhalations TID
• Fluticasone – 2 inhalations BID (3
strengths)
• Fluni...
Leukotriene Modifiers
• Zileuton – 5 Lipoxygenase inhibitor
• Receptor antagonist
– Zafirlukast 20mg BID
– Montelukast 10m...
COPD
• 72 year old smoker for 60yrs
• Cough, sputum production, dyspnea
• FEV1 33% predicted; DLCO 25% predicted
• Rhonchi...
COPD Rx
• Smoking cessation
• Inhaled ipratropium, beta agonist using MDI
• Long acting beta adrenergic - salmeterol
• Flu...
• Calls with low grade fever, dyspnea, ankle
edema
• Admitted to hospital with SaO2 75%
• Oxygen by nasal prongs
• BiPAP (...
Home Oxygen
• SaO2 <89% (or pulmonary hypertension,
Hct >55, CHF)
• Should be used 24hrs day
• After 6 weeks, recheck sats...
• 35 year old female with episodic cough,
wheezing, dyspnea after jogging
• Childhood history of asthma
• Atopic (hay feve...
• Albuterol MDI prior to exercise
• Medication works, but she uses it each
day
• Add inhaled steroids
• Now awakening at n...
• Still having problems with dyspnea, uses
albuterol several times a day
• GERD, Sinus disease
• Increase inhaled steroids...
• Has symptoms of URI, using albuterol every
2hrs, not getting relief
• ED Rx
– Oxygen
– Continuous albuterol
– Intravenou...
Risk of death in Asthma
• Frequent hospitalizations
• Intubated for asthma
• Poor perception of airflow obstruction
• Freq...
Treatment Scheme
• Mild intermittent β-agonists
• Mild persistent + inhaled steroids
• Moderate salmeterol, more
inhaled s...
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  • Pierre: 42% smoked 30yrs ago, now 22%. Lung Cancer 87% are smokers. It is declining.
  • More than 11 PDE enzymes now identified
    PDE4 inhibitors show suppressive activity on various in-vitro responses, including production of cytokines, cell proliferation and chemotaxis, release of inflammatory mediators, and NADPH oxidase activity
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    1. 1. Management of Chronic Airflow Obstruction J.R. Sheller, M.D. Allergy, Pulmonary & Critical Care Medicine
    2. 2. Chronic Airflow Obstruction • Asthma • COPD – emphysema/chronic obstructive bronchitis • Bronchiectasis – cystic fibrosis • Obliterative bronchiolitis
    3. 3. • 12.1 million adults ages 25 and older reported being diagnosed with COPD; 21 million asthmatics • Total estimated cost of COPD $32.1 billion, asthma was $13.8 • COPD is the fourth leading cause of death in the U.S. and is projected to be the third leading cause of death by the year 2020. • 5000 deaths/yr from asthma
    4. 4. Spirometry
    5. 5. Functional residual capacity
    6. 6. FEV1 (%) max Time (yrs) 8020 40 100 50 Disability Death
    7. 7. FEV1 (%) Time (yrs) 8020 40 100 50 Disability Death
    8. 8. Smoking Cessation • Counseling – Has patient thought about stopping? – Rehearse reasons to quit – Offer to help • Group therapy – quitting sessions Cancer Society, Heart Assoc., Lung Assoc. • Medications – Wellbutrin – Nicotine – Clonidine
    9. 9. Bronchodilators • Beta2 adrenergic agonists – By metered dose inhaler – By nebulizer • Short acting – albuterol, terbutaline – rescue medicine • Long acting – salmeterol, formoterol – Not used for “rescue”
    10. 10. Anticholinergics • Ipratropium • Tiatropium Work best in COPD Viral exacerbations of asthma in children
    11. 11. Theophylline • Methylxanthines – adenosine antagonists, phosphodiesterase inhibitors, induces histone deactylase • Narrow therapeutic window • Not important in emergency • May help in difficult cases • Phosphodiesterase 4 inhibitor
    12. 12. Antiinflammatory RX • Can improve function • Can improve symptoms • Uncertain if it alters natural history • May affect structural changes (remodeling)
    13. 13. Inhaled Corticosteroids • Topically active • Delivered to the airway • First pass liver metabolism reduces systemic availability • Unknown mechanism of action
    14. 14. Inhaled Corticosteroids • Theoretical: – suppression of adrenals – growth retardation in kids • Known: – oral thrush and vocal cord dysfunction – Increased cataracts – Increased loss of bone
    15. 15. • Beclomethasone – 2 puffs QID • Triamcinalone – 2 inhalations TID • Fluticasone – 2 inhalations BID (3 strengths) • Flunisolide – 2 inhalations BID • Budesonide – 2 inhalations BID Convenient, cheap
    16. 16. Leukotriene Modifiers • Zileuton – 5 Lipoxygenase inhibitor • Receptor antagonist – Zafirlukast 20mg BID – Montelukast 10mg QD
    17. 17. COPD • 72 year old smoker for 60yrs • Cough, sputum production, dyspnea • FEV1 33% predicted; DLCO 25% predicted • Rhonchi, wheezes, pedal edema DX: Chronic obstructive bronchitis and emphysema http://www.goldcopd.com/
    18. 18. COPD Rx • Smoking cessation • Inhaled ipratropium, beta agonist using MDI • Long acting beta adrenergic - salmeterol • Flu vaccine, pneumovax • Antimicrobials for increased sputum (amoxicillin, doxycycline, macrolides, trimethoprim/sulfa) • Inhaled corticosteroids controversial • Avoid oral steroids
    19. 19. • Calls with low grade fever, dyspnea, ankle edema • Admitted to hospital with SaO2 75% • Oxygen by nasal prongs • BiPAP (non invasive ventilation) • Systemic steroids – iv methylprednisolone, convert to oral (60mg prednisone) • Nebulized ipratropium/albuterol • Pneumovax, influenza vaccine
    20. 20. Home Oxygen • SaO2 <89% (or pulmonary hypertension, Hct >55, CHF) • Should be used 24hrs day • After 6 weeks, recheck sats (50% of patients no longer need it) Home oxygen tethers patients, causing deconditioning Pulmonary rehab, activity are important
    21. 21. • 35 year old female with episodic cough, wheezing, dyspnea after jogging • Childhood history of asthma • Atopic (hay fever) • Normal exam • FEV1 normal; FEV1/FVC reduced
    22. 22. • Albuterol MDI prior to exercise • Medication works, but she uses it each day • Add inhaled steroids • Now awakening at night with cough • Add long acting beta agonist (salmeterol, formoterol; or combination, eg Advair, Symbicort) • Rehearse inhaler use, action plan • Allergy/Pulmonary consultation http://www.nhlbi.nih.gov/about/naepp/
    23. 23. • Still having problems with dyspnea, uses albuterol several times a day • GERD, Sinus disease • Increase inhaled steroids • Add leukotriene modifier Montelukast, zafirlukast – receptor blockers Zileuton – inhibitor of 5-lipoxygenase • Consider theophylline • Anti IgE (omalizumab)
    24. 24. • Has symptoms of URI, using albuterol every 2hrs, not getting relief • ED Rx – Oxygen – Continuous albuterol – Intravenous methylprednisolone 125mg – Ipratropium – Mg may help those with most severe obstruction – Measure PEFR, FEV1, pulsus paradoxus – Admit in 2hrs if no improvement
    25. 25. Risk of death in Asthma • Frequent hospitalizations • Intubated for asthma • Poor perception of airflow obstruction • Frequent albuterol rescue medication use • Psychosocial problems
    26. 26. Treatment Scheme • Mild intermittent β-agonists • Mild persistent + inhaled steroids • Moderate salmeterol, more inhaled steroids, leukotriene modifiers • Severe theophylline, oral steroids, anti IgE
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