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Copd 2006
Copd 2006
Copd 2006
Copd 2006
Copd 2006
Copd 2006
Copd 2006
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Copd 2006
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Copd 2006

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  • 1. COPD 2006 Mark Cucuzzella MD LtCol USAFR Associate Professor Family Medicine West Virginia Rural Family Medicine Program
  • 2. Close to the Beltway but a World Apart
  • 3.  
  • 4. Wayne McLaren…Former Marlboro Man Age 30…a robust young man Age 51…riding into the sunset
  • 5. US Leading Causes of Death 2001
  • 6. % Change in Age Adjusted Death Rate US 1965-1998…gotta die of something
  • 7. Other Sad Facts
    • Direct Cost 2002- 18 Billion
    • Indirect Costs- 14 Billion
    • In US 47 million still smoke
      • 28% males
      • 23% females
    • WHO: 1 billion smokers worldwide…to increase to 1.6 billion 2025. Increasing in lower income areas
  • 8. Objectives of COPD Management
    • Prevent Progression
    • Relieve symptoms
    • Improve exercise tolerance and general health status
    • Prevent and treat exacerbations and complications
    • Minimize treatment side effects
  • 9. Pathophysiology Simplified Bad Genes Breathe Noxious Crap COPD
  • 10. The Real Story
  • 11.  
  • 12. THE Guideline
    • Global Initiative for Chronic Obstructive Lung Disease (GOLD), World Health Organization (WHO), National Heart, Lung and Blood Institute (NHLBI)
  • 13. 4 Keys to Management
    • Assess and Monitor Disease
    • Reduce Risk Factors
    • Manage Stable COPD
      • Education
      • Med management
      • Non med management
    • Treat exacerbations
  • 14. Assess and Monitor Disease Classification of COPD
    • Stage 0 At Risk
    • Stage I Mild COPD
    • Stage II Moderate COPD
    • Stage III Severe COPD
    • Stage IV Very Severe COPD
  • 15. Stage 0 At Risk
    • Normal spirometry
    • Chronic symptoms (cough, sputum, production)
  • 16. Stage I Mild COPD
    • FEV1/FVC <70%
    • FEV1 > 80% predicted
    • With or without chronic symptoms (cough, sputum production)
  • 17. Stage II Moderate COPD
    • FEV1/FVC <70%
    • 50% < FEV1 <80% predicted
    • With or without chronic symptoms (cough, sputum production)
  • 18. Stage III Severe COPD
    • FEV1/FVC <70%
    • 30% < FEV1 <50% predicted
    • With or without chronic symptoms (cough, sputum production)
  • 19. Stage IV Very Severe COPD
    • FEV1/FVC <70%
    • FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure
  • 20. GOLD Guideline in Japan
  • 21. Assess: Who Has Early Stages And Who Do You Test?
    • Test patients with:
      • chronic cough and sputum
      • exposure to risk factors
      • even if no dyspnea
    • Early Stage:
      • airflow limitation that is not fully reversible
      • with or without the presence of symptoms
  • 22. Assess for COPD: A Common Story
    • Cough
      • intermittent or daily
      • present throughout day- seldom only nocturnal
    • Sputum
      • Any pattern of chronic sputum production
    • Dyspnea
      • Progressive and Persistent
      • &quot;increased effort to breathe&quot; &quot;heaviness&quot; &quot;air hunger&quot; or &quot;gasping&quot;
      • Worse on exercise
      • Worse during respiratory infections
    • Exposure to risk factors
      • Tobacco smoke
      • Occupational dusts and chemicals
      • Smoke from home cooking and heating fuels
  • 23. Assess: Spirometry to Diagnose
      • FEV1/FVC <70% and a postbronchodilator FEV1 <80% predicted confirms the presence of airflow limitation that is not fully reversible.
      • Must have access to spirometry
  • 24. Assess: Medical History in Those With Established Disease
    • Exacerbations or hospitalizations?
    • Comorbidities that contribute to restriction of activity
    • Appropriateness of current medical treatments
    • Impact of disease on patient's life
      • limitation of activity
      • missed work and economic impact
      • effect on family routines
      • depression or anxiety
    • Social and family support
    • Possibilities for reducing risk factors, esp smoking
  • 25. Assess: Physical Examination
    • Rarely diagnostic in COPD
    • Physical signs of airflow limitation
      • rarely present until significant impairment of lung function
      • low sensitivity and specificity
  • 26. Assess: Measure Airflow Limitation
    • Patients with COPD typically show a decrease in both FEV1 and FVC
    • Postbronchodilator FEV1 <80% predicted + FEV1/FVC <70% confirms the presence of airflow limitation that is not fully reversible
    • FEV1/FVC <70% is an early sign of airflow limitation in patients whose FEV1 remains normal ( > 80% predicted).
  • 27. Assess: Severity
    • Based on the patient's level of symptoms
    • Severity of the spirometric abnormality
    • Presence of complications such as respiratory failure and right heart failure
  • 28. Assess: Additional Investigations > Stage II: Moderate COPD
    • Bronchodilator reversibility testing
      • rule out asthma
      • establish best attainable lung function
      • gauge a patient's prognosis
      • guide treatment decisions
    • Chest x-ray
      • seldom diagnostic unless obvious bullous disease
      • valuable in excluding alternative diagnoses
      • CT not routinely recommended
  • 29. Assess: Additional Investigations > Stage II: Moderate COPD
    • Arterial blood gas measurement
      • In advanced COPD: FEV1 <40% predicted or with clinical signs suggestive of respiratory failure or right heart failure
      • central cyanosis, ankle swelling, JVD
      • Respiratory failure
        • PaO2 < 60 mm Hg +/- PaCO2 >50 mm Hg at sea level
    • Alpha-1 antitrypsin deficiency screening
      • COPD at a young age
      • strong family history of the disease
  • 30. Differential Diagnosis
    • A major differential diagnosis is asthma
    • In some patients with chronic asthma, a clear distinction from COPD is not possible
    • In these cases, current management is similar to that of asthma
    • Other potential diagnoses are usually easier to distinguish from COPD
  • 31. COPD
    • Onset in mid-life
    • Symptoms slowly progressive
    • Long smoking history
    • Dyspnea during exercise
    • Largely irreversible airflow limitation
  • 32. Asthma
    • Onset early in life (often childhood)
    • Symptoms vary from day to day
    • Symptoms at night/early morning
    • Allergy, rhinitis, and/or eczema also present
    • Family history of asthma
    • Largely reversible airflow limitation
  • 33. Congestive Heart Failure
    • Fine basilar crackles on auscultation
    • Chest x-ray shows dilated heart, pulmonary edema
    • PFTs indicate restriction - not obstruction
    • BNP can help
  • 34. Other Diff Dx to Consider
    • Bronchiectasis
      • Large volumes of purulent sputum
      • bacterial infection
      • CXR/CT shows bronchial dilation, bronchial wall thickening
    • TB
      • History with the usual suspects
    • BOO and BOOP
      • nonsmokers
      • environmental exposures
      • CT on expiration shows hypodense areas
  • 35. Monitoring: This is a progressive disease
    • Lung function worsens over time- even with best care
    • Monitor symptoms and objective measures of airflow limitation for development of complications and to determine when to adjust therapy
    • Spirometry should be performed if there is a substantial increase in symptoms or a complication
    • ABG should be considered in all patients with an FEV1 <40% predicted or clinical signs of respiratory failure or right heart failure (JVD/edema)
  • 36. Reduce Risk Factors
  • 37. Reduce Risk Factors: Key Points
    • Reducting exposure to tobacco smoke, occupational dusts, and chemicals, and indoor and outdoor air pollutants
    • Smoking cessation is the single most effective -- and cost-effective -- intervention to reduce the risk of developing COPD and stop its progression (Evidence A)
  • 38. Reduce Risk Factors: Key Points
    • Brief tobacco dependence treatment is effective (Evidence A) and every tobacco user should be offered at least this treatment at every visit
    • Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A)
  • 39. Reduce Risk Factors: Key Points
    • There are effective pharmacotherapies for tobacco dependence (Evidence A)
    • Add meds to counseling if necessary
    • Progression of many occupationally induced respiratory disorders can be reduced or controlled by reducing inhaled particles and gases (Evidence B)
  • 40. Maybe This Would be Better Than Drugs
  • 41. Manage Stable COPD Key Points 1
    • Stepwise increase in treatment based on disease severity
    • Health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation (Evidence A) .
    • None of the existing medications for COPD affects long-term decline in lung function that is the hallmark of this disease (Evidence A)
    • Pharmacotherapy for COPD is used to decrease symptoms and/or complications
  • 42. Manage Stable COPD Key Points 2
    • Bronchodilators central to symptom management (Evidence A)
    • PRN or regular basis to reduce symptoms
    • Use beta2-agonist, anticholinergic, theophylline, or a combination of one or more of these drugs (Evidence A)
    • Regular treatment with LABs is slightly more effective and convenient than with SABs, but more expensive (Evidence A)
    • TECHNIQUE IS KEY
    • MDI BETTER THAN NEB IF USED CORRECTLY
  • 43. Manage Stable COPD Key Points 3
    • Add inhaled steroids to bronchodilators for symptomatic COPD patients with an FEV1 <50% predicted (Stage III: Severe COPD and Stage IV Very Severe COPD) and repeated exacerbations (Evidence A)
    • Avoid chronic treatment with systemic steroids - unfavorable benefit-to-risk ratio (Evidence A
  • 44. Manage Stable COPD Key Points 3
    • The long-term O2 with chronic respiratory failure increases survival (Evidence A)
    • Improves exercise tolerance
    • If hypercapnic titrate SpO2 to 88-90%
    • Walk your clinic patients if RA SpO2 OK
  • 45. Manage Stable COPD Key Points 4
    • All COPD patients benefit from exercise training program
    • Improves both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A)
  • 46. Medications
  • 47. Bronchodilators Beta2-agonists
    • Short-acting
      • Fenoterol
      • Salbutamol (albuterol)
      • Terbutaline
    • Long-acting
      • Formoterol
      • Salmeterol
  • 48. Bronchodilators Anticholinergics
    • Mode of Action
      • Cholinergic tone is only reversible component of COPD
      • Normal airway have small degree of vagal cholinergic tone
    • Short-acting
      • Ipratropium bromide
      • Oxitropium bromide
    • Long-acting
      • Tiotropium
  • 49. Bronchodilators- Combos and Methylxanthines
    • Combination beta2-agonists plus anticholinergic in one inhaler
      • Fenoterol/Ipratropium
      • Salbutamol/Ipratropium
    • Methylxanthines
      • Aminophylline (slow release preparations)
      • Theophylline (slow release preparations)
      • RARELY OF SIGNIFICNAT BENEFIT
      • LEVEL 8-12 mcg/ml
  • 50. Other Med Adjuncts?
    • Influenza vaccines significantly reduce serious illness and death (Evidence A)
    • Pneumococcal vaccine –OK to use but data lacking (Evidence B)
    • Antibiotics: other than treating infectious exacerbations- not recommended (Evidence A)
    • Mucolytic Agents : a few patients with viscous sputum may benefit but the widespread use cannot be recommended (Evidence D)
    • Antitussives : Cough, a troublesome symptom in COPD, has a protective role. Regular use of antitussives contraindicated (Evidence D)
    • Narcotics : The use of PO and IV opioids effective for dyspnea in advanced disease
  • 51. Therapy by Stage- Pretty Simple
  • 52.
    • “ Make everything as simple as possible, but not one bit simpler”
    • Einstein
  • 53. Manage Exacerbations
    • Do you admit? You and your patient decide….little guidance in the literature
  • 54. Manage Exacerbations 1
    • Infection of tracheobronchial tree and air pollution are most common causes
    • Cause of about 1/3 of severe exacerbations cannot be identified
  • 55. Manage Exacerbations 2
      • (Evidence A) treatment
        • Inhaled bronchodilators (beta2-agonists and/or anticholinergics)
        • Systemic, preferably oral, glucocorticosteroids
      • (Evidence B) Antibiotic treatment if signs of airway infection
          • increased volume/change of color of sputum
          • fever
      • O2 of course….but caution with retainers….I’m getting sleepy
      • Little evidence for Methyxanthines
  • 56. Manage Exacerbations 3
      • Noninvasive intermittent positive pressure ventilation (NIPPV) improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A)
      • BIPAP is Best!
        • Set FiO2, inspiratory (IPAP) and expiratory (EPAP)
        • Difference between IPAP and EPAP augments tidal volume and improves minute ventilation
        • CO2 gets blown off
  • 57. Questions?

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