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    copd copd Presentation Transcript

    • COPD
        • I have SOB X 3days
        • 62 yo/M with PMH COPD, HTN, DM-2, PROSTATE CANCER, H/O CVA came with SOB X 3 days, productive sputum, whitish in color associated with chest pain which increases during inspiration.
        • H/o of preceding common cold(URTI) but no h/o fever.
    • s
        • Meds-metformin,lasix,nph-insulin,lisinopril,
        • Atenolol,cardura, zocor, nexium.
        • Allergy-None
        • Smoking+
        • Etoh+ve
        • No drugs
        • ER vitals-98/92/40//163/84—98%
        • Floor vitals-98/88/22//135/65—98%
        • Pt in mild distress
        • No JVD,No edema
        • Chest-Use of accessory muscles , B/L diffuse wheezing,crepts+
        • CVS/PA/EXT-wnl
        • CBC-WBC-11.4,H/H-13.9/42.1, PLT-316
        • BMP-N/K-140/4.6,CL/HCO3-104/27
        • -BUN/CR-15/1, B.Sugar-122
        • LFT-3.5/6.7/18/20/0.4/113
        • CXR-Interstistial lung disease
        • Blood cx-p
    • Chronic Obstructive Pulmonary Disease (COPD) Morning report PGY-2 Kanth, Rajan
    • Learning Objectives: To be able to…
        • Conduct a relevant P.E. and interpret the findings in a patients with suspected COPD
        • Identify medication and non-medication interventions for managing COPD
        • Identify steps in the outpatient medical management for acute exacerbation of COPD and criteria for hospitalization
    • Overview
        • Definition, epidemiology and pathophysiology
        • Diagnsosis and Assessment (2 cases)
        • Management
          • Risk factor reduction
          • Stable chronic COPD
          • Acute exacerbations of COPD
    • Definition of COPD *
        • COPD is a preventable and treatable chronic lung disease characterized by airflow limitation that is not fully reversible.
        • The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung.
      * Adapted from the Global Initiative for Chronic Obstructive Lung Disease 2007
    • Epidemiology of COPD
        • COPD is a leading cause of mortality worldwide and projected to increase in the next several decades.
        • COPD mortality trends generally track several decades behind smoking trends.
        • In the US and Canada, COPD mortality for both men and women have been increasing.
        • In the US in 2000, the number of COPD deaths was greater among women than men.
    • Percent Change from 1965 in Age-Adjusted Death Rates, U.S., 1965-1998 0 0.5 1.0 1.5 2.0 2.5 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 – 59% – 64% – 35% +163% – 7% Coronary Heart Disease Stroke Other CVD COPD All Other Causes Source : NHLBI/NIH/DHHS
    • COPD Mortality by Gender, U.S., 1980-2000 Number Deaths x 1000 Source: US Centers for Disease Control and Prevention, 2002 – cited in GOLD 2007
    • Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations
    • Pathophysiology of COPD
        • Chronic inflammation, bronchial wall edema, mucous secretion, hyperinflation and air trapping
        • Increase in proteinases compared to antiproteinases and in free radicals leading to parenchymal destruction
        • Changes in pulmonary vasculature leading to ventilation-perfusion mismatching, pulmonary hypertension, cor pulmonale
    • LUNG INFLAMMATION COPD PATHOLOGY Oxidative stress Proteinases Repair mechanisms Anti-proteinases Anti-oxidants Host factors Amplifying mechanisms Cigarette smoke Biomass particles Particulates Source : GOLD 2007 Pathogenesis of COPD
    • Disrupted alveolar attachments Inflammatory exudate in lumen Peribronchial fibrosis Lymphoid follicle Thickened wall with inflammatory cells - macrophages, CD8 + cells, fibroblasts Changes in Small Airways in COPD Patients Source : COLD 2007
    • Alveolar wall destruction Loss of elasticity Destruction of pulmonary capillary bed ↑ Inflammatory cells macrophages, CD8 + lymphocytes Source : GOLD 2007 Changes in Lung Parenchyma in COPD
    • Chronic hypoxia Pulmonary vasoconstriction Muscularization Intimal hyperplasia Fibrosis Obliteration Pulmonary hypertension Cor pulmonale Death Edema Pulmonary Hypertension in COPD Source : GOLD 2007
    • Diagnosis and Assessment of COPD
    • Patient LG
        • 54 year old man with a 80+ pack-year smoking history, presents with dyspnea while climbing stairs and an occasional, non-productive cough
        • What would you look for/expect on exam?
    • Patient LG : Examination
        • Diminished breath sounds on auscultation
        • Forced expiratory time of > 6 seconds
        • Decreased I/E ratio
        • Increased thoracic circumference and decreased change with respiration
        • Increased resonance to percussion
    • Patient EC
        • 62 year woman with 40 p-yr history presents with chronic cough for 3 months, productive of clear to light yellow phlegm
        • What would you look for/expect on exam?
    • Patient EC
        • Rhonchus breath sounds
        • 1+ ankle edema
    • Patients LG and EC
        • What tests would you order?
    • Diagnosis and Assessment
        • A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.
        • The diagnosis should be confirmed by spirometry. A post-bronchodilator FEV 1 /FVC < 0.70 confirms the presence of airflow limitation that is not fully reversible.
    • Spirometry: Normal and Patients with COPD
    • Classification of COPD Severity by Spirometry post Bronchodilator* Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure * Adapted from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2007
    • Patient LG : Test Results
        • CXR – Hyperinflation and increased lucency
        • FEV1/FEV=.55
        • FEV1=40%
    • Patient EC: Test Results
        • CXR – peribronchial thickening
        • FEV1/FEV=.60
        • FEV1=55%
    • Patient LG
        • 54 year old man with a 80+ pack-year smoking history, presents with dyspnea while gardening, occasional, non- productive cough
        • What is his condition?
    • Patient EC
        • 62 year woman with 40 p-yr history presents with chronic cough for 3 months, productive of clear to light yellow phlegm
        • What is her condition?
    • Differential Diagnosis: COPD and Asthma COPD ASTHMA
        • Onset in mid-life
        • Symptoms slowly progressive
        • Long smoking history
        • Dyspnea during exercise
        • Largely irreversible airflow
      • limitation
        • 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
    • Management of COPD
        • Relieve symptoms
        • Prevent disease progression
        • Improve exercise tolerance
        • Improve health status
        • Prevent and treat complications
        • Prevent and treat exacerbations
        • Reduce mortality
    • General Points
        • Only smoking cessation and O2 therapy (when indicated) have been shown to prolong survival
        • Other therapies aimed at relieving symptoms, improving quality of life, reducing exacerbations and need for hospitalizations
    • Risk Factor Reduction
        • Smoking cessation (prolongs survival)
        • Avoid exposure to second hand cigarette smoke
        • Reduction of exposure to indoor and outdoor pollution
        • Influenza vaccine
        • Pneumococcal vaccines
    • Brief Strategies to Help the Patient Willing to Quit Smoking
        • ASK Systematically identify all tobacco users at every visit.
        • ADVISE Strongly urge all tobacco users to quit. (e ven a brief (3-minute) period of counseling to quit results in smoking cessation in 5-10% of patients.)
        • ASSESS Determine willingness to make a quit attempt (stages of change).
        • ASSIST Aid the patient in quitting.
        • ARRANGE Schedule follow-up contact .
    • IV: Very Severe III: Severe II: Moderate I: Mild Therapy at Each Stage of COPD
        • FEV 1 /FVC < 70%
        • FEV 1 > 80% predicted
        • FEV 1 /FVC < 70%
        • 50% < FEV 1 < 80%
      • predicted
        • FEV 1 /FVC < 70%
        • 30% < FEV 1 < 50% predicted
        • FEV 1 /FVC < 70%
        • FEV 1 < 30% predicted
      • or FEV 1 < 50% predicted plus chronic respiratory failure
      Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add long term oxygen if chronic respiratory failure. Consider surgical treatments
    • Treatment of Stable COPD: Bronchodilators
        • Bronchodilator medications are central to the symptomatic management of COPD (Evidence A).
        • They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms and exacerbations.
        • The principal bronchodilator treatments are ß 2 - agonists and anticholinergics used singly or in combination
        • Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators
    • Treatment of Stable COPD: Inhaled Glucocorticoids
        • Consider adding regular treatment with inhaled glucocorticosteroids to bronchodilator treatment is for symptomatic COPD patients with an FEV1 < 50% predicted ( Stage III and IV) and repeated exacerbations (Evidence A).
        • An inhaled glucocorticosteroid combined with a long-acting ß2-agonist is more effective than the individual components (Evidence A).
    • Treatment of Stable COPD Other Medications
        • Chronic oral Prednisone
          • Use in chronic COPD is controversial. No effect on survival. May improve symptoms and reduce hospitalizations in some patients already at maximum treatment
        • Mucolytics & Expectorants (SSKI, guafenesin)
          • Relives symptoms from copious, viscous secretions
        • Oral Theophylline
          • If inhalers not sufficient
          • Side effects common
    • Treatment of Stable COPD: Home Oxygen Therapy
        • > 15 hours/day reduces mortality
        • Criteria for O2 therapy
          • Pa O2 < 55 mm Hg (O2 saturation < 88%) at rest or during exercise or sleep or
          • Pa O2 < 60 mm Hg and hematocrit >52%
        • Bipap when sleeping may provide additional improvement
    • Treatment of Stable COPD: Pulmonary Rehabilitation and Patient Education
        • Typically includes exercise, education and psychological support
        • Shown to improve symptoms, exercise capacity, reduce use of medical care, reduce anxiety and depression
    • Treatment of Stable COPD: Surgery
        • Primarily for patients with emphysema
        • Few RCTs, no evidence for improvement in mortality but can relieve symptoms
        • Improves QOL and exercise capacity in patients with primarily upper lobe disease, low exercise capacity, and FEV1 between 20 and 30%
        • Lung transplantation
    • Treatment of Acute Exacerbations of COPD
    • Acute Exacerbations of COPD
        • The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified.
    • Outpatient Treatment of Acute Exacerbations: Bronchodilators
        • Inhaled bronchodilators (particularly inhaled ß 2 -agonists with or without anticholinergics) are effective treatment for exacerbations of COPD ( LOE: A ).
    • Outpatient Treatment of Acute Exacerbations: Prednisone
        • Oral prednisone is effective treatment for exacerbations of COPD (LOE: A).
    • Outpatient Treatment of COPD Exacerbation: Antibiotics
        • Surprisingly little evidence of efficacy
        • Typically use in patients with purulent sputum or other signs of infection
        • Amoxicillin, doxycycline, azithromycin, trimethoprim-sulfa are reasonable first line choices
    • Indications for Hospital Admission of Patient with Acute Exacerbation
        • Resting dyspnea after initial treatment
        • Lack of response to initial treatment
        • Significant co-morbid conditions)
        • Severe underlying COPD/prior ICU ventilation for exacerbations
        • New physical signs (e.g., new peripheral edema)
        • Diagnostic uncertainty
        • Insufficient home support
    • Inpatient Treatment of Acute Exacerbations
        • Oxygen to keep O2 sat >90%
        • Nebulizer treatments with bronchodilators
        • Steroids (LOE A)
          • (40 to 60 mg daily for 7 to 14 days, IV or PO)
        • Antibiotics (LOE B)–
          • Typically ceftriaxzone (1 gram IV q 24 h) + doxycycline (100 mg po q 12 h) at SFGH
        • Fluids
    • The End Thank you