ECI COPD Course Lecture 3


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ECI COPD Course Lecture 3

  1. 1. Assessment of the Patientwith COPD
  2. 2. Patient Assessment: COPDHistoryCombined GOLD 2011 assessmentPhysical findingsRadiography
  3. 3. History: COPDFamily historySmokingOccupationDyspneaWheezingSputum production
  4. 4. Genetic Factors: COPDα-1 antitrypsin deficiency ▫ COPD before age 45 ▫ COPD but have never smoked or been exposed to toxins ▫ Family history of COPD ▫ Concomitant liver disease ▫ Alpha-l antitrypsin level measured in the blood to confirm diagnosisOther single nucleotide polymorphisms
  5. 5. Exposure to Noxious ParticlesGOLD 2013
  6. 6. Stop smoking Strategies
  7. 7. COPD Phenotypes Pink Puffer Blue Bloater
  8. 8. COPD Phenotypes
  9. 9. COPD versus Asthma COPD Asthma• Onset in mid-life • Onset early in life• Slowly progressive • Symptoms vary day to day• Long smoking history • Symptoms at night• Dyspnea during exercise • Allergy, rhinitis, and/or• Irreversible airflow eczema present limitation • Family history of asthma • Reversible airflow limitation
  10. 10. The Goals of COPD assessment To Determine: The severity of the disease The impact on the patient’s health status The risk of future events.( such as exacerbations, hospital admissions or death) GOLD 2013
  11. 11. GOLD 2013 Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities GOLD 2013
  12. 12. GOLD 2013 Assessment of COPD based on symptoms and future risk Assess symptoms COPD Assessment Test (CAT) Modified Medical Research Council Breathlessness scale (mMRC)Adapted from GOLD 2013
  13. 13. COPD Assessment Test (CAT) Largely patient-driven item inclusion 25% of items concerned with breathlessness or activity Scoring range 0-40Jones et al; Eur Respir J 2009; 34: 648–654
  14. 14. Modified MRC Dyspnoea Scale (mMRC) Grade 0: Breathless on strenuous exercise Grade 1: Short of breath when hurrying or walking up a slight hill Grade 2: Walk slower than others or stop when walking at own pace on level ground Grade 3: Stop every 100m or after a few minutes Grade 4: Too breathless to leave the house or breathless on washing/dressingAm Rev Respir Dis;1987;135(6):1229-33
  15. 15. GOLD 2013Assessment of COPD based on symptoms and future risk Assess degree of airflow limitation (Spirometry) Spirometric classification of airflow limitation (in patients with FEV1/FVC<0.70) GOLD 1 (Mild; FEV1 ≥80% predicted) GOLD 2 (Moderate; 50% ≤FEV1 <80% predicted) GOLD 3 (Severe; 30% ≤FEV1 <50% predicted) GOLD 4* (Very severe; FEV1 <30% predicted)Adapted from GOLD 2013
  16. 16. Assessment of Exacerbation RiskAn exacerbation of COPD is defined as:“an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication”The best predictor of having frequent exacerbations (2 or more exacerbations per year) is a history of previous treated events
  17. 17. Assessment of Exacerbation Risk“The patients own history of exacerbations appears to be the most powerful predictor of future exacerbations”The risk of Exacerbations significantly increases in GOLD 3 (Severe) and GOLD 4 (Very Severe)There are two methods of assessing exacerbation risk. ▫ Using the GOLD spirometric classification with GOLD 3 or GOLD 4 categories indicating high risk ▫ The other is based on individual patient’s history of exacerbation with two or more exacerbations in the preceding year indicating high risk
  18. 18. Assessment of COPD based on symptoms and future risk Assess risk of exacerbations History of exacerbations SpirometryAdapted from GOLD 2013
  19. 19. Combined assessment of COPD Assess symptoms first Assess risk of exacerbations next When assessing risk, choose the highest risk according to GOLD grade or exacerbation history. (one or more hospitalizations for COPD exacerbations should be considered high risk) Patient is now in one of four categories Adapted from GOLD 2013
  20. 20. Combined assessment of COPD GOLD 4 ≥2 More symptoms GOLD 3 Less symptoms EXACERBATION /YEARSPIROMETRIC CLASSIFICATION high risk High risk GOLD 2 <2 Less symptoms More symptoms GOLD 1 Low risk low risk mMRC 01 mMRC ≥2 Adapted from GOLD 2013 CAT <10 SYMPTOMS CAT ≥10
  21. 21. Assessment of COPD based on symptoms and future risk Assess comorbidities Comorbidities should be actively looked for and treated appropriately Most frequent comorbidities are cardiovascular disease, depression and osteoporosisAdapted from GOLD 2013
  22. 22. Comorbidities: COPDIncreased risk for: Significant systemic • Myocardial infarction effects: • Angina • Weight loss/gain • Diabetes • Nutritional abnormalities • Respiratory infection • Skeletal muscle • Bone fractures dysfunction • Depression • Osteoporosis • Lung cancer • Sleep disorders • Anemia
  23. 23. Comorbidities in COPD Comorbidities COPD If smoker
  24. 24. Physical Exam: COPDHyperinflationAccessory muscle usePursed lipsEdemaBreathing patternAuscultationBody mass index (BMI)
  25. 25. Barrel Chest Clubbing does not occur with COPD; if present, seek an alternative or comorbid condition
  26. 26. Pursed Lips; ProlongedExhalation
  27. 27. COPD: AuscultationDecreased breath sounds: hyperinflationProlonged exhalationWheezing, rhonchiCrackles: heart failure
  28. 28. Body Mass index, airflow Obstruction,Dyspnea and Exercise capacity
  29. 29. COPD: 6MWT Walking course 30m in length. Corridor marked every 3m. Turnaround points marked with a cone (such as orange traffic cone). Starting line, which marks the beginning and end of each 6o-m lap, marked on the floor using brightly colored tape.
  30. 30. COPD: RadiographyHyperinflation: lowered flattened diaphragmInfiltrates with infectionPneumothorax
  31. 31. Arterial Blood GasesHypoxemia and hypercapnia develop as disease process worsensSp02 can be problematic: accuracy ±5o/o, not good assessment of hypercapniaCapnography underestimates PaC02 due to dead space
  32. 32. COPD ExacerbationsPrimary Symptoms: Secondary Symptoms: • Malaise ▫ Increased dyspnea • Insomnia ▫ Increased cough and • Sleepiness sputum • Fatigue ▫ Change sputum • Depression ▫ Impaired daily activities • Confusion • Wheezing • Tightness of chest • Chest pain • Tachycardia • Tachypnea
  33. 33. Diagnosis of COPD A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production and a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis; the presence of a post- bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.
  34. 34. COPD diagnosis SYMPTOMS HISTORY OF EXPOSURE FAMILY Dyspnea-progressive TO RISK FACTORS HISTORY OF (worsens over time and Tobacco smoke COPD with exercise) Smoke from home Chronic cough cooking/heating fuels Sputum Occupational dusts and chemicals SPIROMETRY REQUIRED TO DIAGNOSE COPD presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.Adapted from GOLD 2013