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  1. 1. COPD
  2. 2. <ul><ul><li>I have SOB X 3days </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>H/o of preceding common cold(URTI) but no h/o fever. </li></ul></ul>
  3. 3. s <ul><ul><li>Meds-metformin,lasix,nph-insulin,lisinopril, </li></ul></ul><ul><ul><li>Atenolol,cardura, zocor, nexium. </li></ul></ul><ul><ul><li>Allergy-None </li></ul></ul><ul><ul><li>Smoking+ </li></ul></ul><ul><ul><li>Etoh+ve </li></ul></ul><ul><ul><li>No drugs </li></ul></ul>
  4. 4. <ul><ul><li>ER vitals-98/92/40//163/84—98% </li></ul></ul><ul><ul><li>Floor vitals-98/88/22//135/65—98% </li></ul></ul><ul><ul><li>Pt in mild distress </li></ul></ul><ul><ul><li>No JVD,No edema </li></ul></ul><ul><ul><li>Chest-Use of accessory muscles , B/L diffuse wheezing,crepts+ </li></ul></ul><ul><ul><li>CVS/PA/EXT-wnl </li></ul></ul>
  5. 5. <ul><ul><li>CBC-WBC-11.4,H/H-13.9/42.1, PLT-316 </li></ul></ul><ul><ul><li>BMP-N/K-140/4.6,CL/HCO3-104/27 </li></ul></ul><ul><ul><li>-BUN/CR-15/1, B.Sugar-122 </li></ul></ul><ul><ul><li>LFT-3.5/6.7/18/20/0.4/113 </li></ul></ul><ul><ul><li>CXR-Interstistial lung disease </li></ul></ul><ul><ul><li>Blood cx-p </li></ul></ul>
  6. 9. Chronic Obstructive Pulmonary Disease (COPD) Morning report PGY-2 Kanth, Rajan
  7. 10. Learning Objectives: To be able to… <ul><ul><li>Conduct a relevant P.E. and interpret the findings in a patients with suspected COPD </li></ul></ul><ul><ul><li>Identify medication and non-medication interventions for managing COPD </li></ul></ul><ul><ul><li>Identify steps in the outpatient medical management for acute exacerbation of COPD and criteria for hospitalization </li></ul></ul>
  8. 11. Overview <ul><ul><li>Definition, epidemiology and pathophysiology </li></ul></ul><ul><ul><li>Diagnsosis and Assessment (2 cases) </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Risk factor reduction </li></ul></ul></ul><ul><ul><ul><li>Stable chronic COPD </li></ul></ul></ul><ul><ul><ul><li>Acute exacerbations of COPD </li></ul></ul></ul>
  9. 12. Definition of COPD * <ul><ul><li>COPD is a preventable and treatable chronic lung disease characterized by airflow limitation that is not fully reversible. </li></ul></ul><ul><ul><li>The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung. </li></ul></ul>* Adapted from the Global Initiative for Chronic Obstructive Lung Disease 2007
  10. 13. Epidemiology of COPD <ul><ul><li>COPD is a leading cause of mortality worldwide and projected to increase in the next several decades. </li></ul></ul><ul><ul><li>COPD mortality trends generally track several decades behind smoking trends. </li></ul></ul><ul><ul><li>In the US and Canada, COPD mortality for both men and women have been increasing. </li></ul></ul><ul><ul><li>In the US in 2000, the number of COPD deaths was greater among women than men. </li></ul></ul>
  11. 14. 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
  12. 15. 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
  13. 16. Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations
  14. 17. Pathophysiology of COPD <ul><ul><li>Chronic inflammation, bronchial wall edema, mucous secretion, hyperinflation and air trapping </li></ul></ul><ul><ul><li>Increase in proteinases compared to antiproteinases and in free radicals leading to parenchymal destruction </li></ul></ul><ul><ul><li>Changes in pulmonary vasculature leading to ventilation-perfusion mismatching, pulmonary hypertension, cor pulmonale </li></ul></ul>
  15. 19. 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
  16. 20. 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
  17. 21. 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
  18. 22. Chronic hypoxia Pulmonary vasoconstriction Muscularization Intimal hyperplasia Fibrosis Obliteration Pulmonary hypertension Cor pulmonale Death Edema Pulmonary Hypertension in COPD Source : GOLD 2007
  19. 23. Diagnosis and Assessment of COPD
  20. 24. Patient LG <ul><ul><li>54 year old man with a 80+ pack-year smoking history, presents with dyspnea while climbing stairs and an occasional, non-productive cough </li></ul></ul><ul><ul><li>What would you look for/expect on exam? </li></ul></ul>
  21. 25. Patient LG : Examination <ul><ul><li>Diminished breath sounds on auscultation </li></ul></ul><ul><ul><li>Forced expiratory time of > 6 seconds </li></ul></ul><ul><ul><li>Decreased I/E ratio </li></ul></ul><ul><ul><li>Increased thoracic circumference and decreased change with respiration </li></ul></ul><ul><ul><li>Increased resonance to percussion </li></ul></ul>
  22. 26. Patient EC <ul><ul><li>62 year woman with 40 p-yr history presents with chronic cough for 3 months, productive of clear to light yellow phlegm </li></ul></ul><ul><ul><li>What would you look for/expect on exam? </li></ul></ul>
  23. 27. Patient EC <ul><ul><li>Rhonchus breath sounds </li></ul></ul><ul><ul><li>1+ ankle edema </li></ul></ul>
  24. 28. Patients LG and EC <ul><ul><li>What tests would you order? </li></ul></ul>
  25. 29. Diagnosis and Assessment <ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  26. 30. Spirometry: Normal and Patients with COPD
  27. 31. 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
  28. 32. Patient LG : Test Results <ul><ul><li>CXR – Hyperinflation and increased lucency </li></ul></ul><ul><ul><li>FEV1/FEV=.55 </li></ul></ul><ul><ul><li>FEV1=40% </li></ul></ul>
  29. 33. Patient EC: Test Results <ul><ul><li>CXR – peribronchial thickening </li></ul></ul><ul><ul><li>FEV1/FEV=.60 </li></ul></ul><ul><ul><li>FEV1=55% </li></ul></ul>
  30. 34. Patient LG <ul><ul><li>54 year old man with a 80+ pack-year smoking history, presents with dyspnea while gardening, occasional, non- productive cough </li></ul></ul><ul><ul><li>What is his condition? </li></ul></ul>
  31. 35. Patient EC <ul><ul><li>62 year woman with 40 p-yr history presents with chronic cough for 3 months, productive of clear to light yellow phlegm </li></ul></ul><ul><ul><li>What is her condition? </li></ul></ul>
  32. 36. Differential Diagnosis: COPD and Asthma COPD ASTHMA <ul><ul><li>Onset in mid-life </li></ul></ul><ul><ul><li>Symptoms slowly progressive </li></ul></ul><ul><ul><li>Long smoking history </li></ul></ul><ul><ul><li>Dyspnea during exercise </li></ul></ul><ul><ul><li>Largely irreversible airflow </li></ul></ul><ul><li>limitation </li></ul><ul><ul><li>Onset early in life (often childhood) </li></ul></ul><ul><ul><li>Symptoms vary from day to day </li></ul></ul><ul><ul><li>Symptoms at night/early morning </li></ul></ul><ul><ul><li>Allergy, rhinitis, and/or eczema also present </li></ul></ul><ul><ul><li>Family history of asthma </li></ul></ul><ul><ul><li>Largely reversible airflow limitation </li></ul></ul>
  33. 37. Management of COPD
  34. 38. <ul><ul><li>Relieve symptoms </li></ul></ul><ul><ul><li>Prevent disease progression </li></ul></ul><ul><ul><li>Improve exercise tolerance </li></ul></ul><ul><ul><li>Improve health status </li></ul></ul><ul><ul><li>Prevent and treat complications </li></ul></ul><ul><ul><li>Prevent and treat exacerbations </li></ul></ul><ul><ul><li>Reduce mortality </li></ul></ul>GOALS of COPD MANAGEMENT
  35. 39. General Points <ul><ul><li>Only smoking cessation and O2 therapy (when indicated) have been shown to prolong survival </li></ul></ul><ul><ul><li>Other therapies aimed at relieving symptoms, improving quality of life, reducing exacerbations and need for hospitalizations </li></ul></ul>
  36. 40. Risk Factor Reduction <ul><ul><li>Smoking cessation (prolongs survival) </li></ul></ul><ul><ul><li>Avoid exposure to second hand cigarette smoke </li></ul></ul><ul><ul><li>Reduction of exposure to indoor and outdoor pollution </li></ul></ul><ul><ul><li>Influenza vaccine </li></ul></ul><ul><ul><li>Pneumococcal vaccines </li></ul></ul>
  37. 41. Brief Strategies to Help the Patient Willing to Quit Smoking <ul><ul><li>ASK Systematically identify all tobacco users at every visit. </li></ul></ul><ul><ul><li>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.) </li></ul></ul><ul><ul><li>ASSESS Determine willingness to make a quit attempt (stages of change). </li></ul></ul><ul><ul><li>ASSIST Aid the patient in quitting. </li></ul></ul><ul><ul><li>ARRANGE Schedule follow-up contact . </li></ul></ul>
  38. 42. IV: Very Severe III: Severe II: Moderate I: Mild Therapy at Each Stage of COPD <ul><ul><li>FEV 1 /FVC < 70% </li></ul></ul><ul><ul><li>FEV 1 > 80% predicted </li></ul></ul><ul><ul><li>FEV 1 /FVC < 70% </li></ul></ul><ul><ul><li>50% < FEV 1 < 80% </li></ul></ul><ul><li>predicted </li></ul><ul><ul><li>FEV 1 /FVC < 70% </li></ul></ul><ul><ul><li>30% < FEV 1 < 50% predicted </li></ul></ul><ul><ul><li>FEV 1 /FVC < 70% </li></ul></ul><ul><ul><li>FEV 1 < 30% predicted </li></ul></ul><ul><li>or FEV 1 < 50% predicted plus chronic respiratory failure </li></ul>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
  39. 43. Treatment of Stable COPD: Bronchodilators <ul><ul><li>Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). </li></ul></ul><ul><ul><li>They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms and exacerbations. </li></ul></ul><ul><ul><li>The principal bronchodilator treatments are ß 2 - agonists and anticholinergics used singly or in combination </li></ul></ul><ul><ul><li>Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators </li></ul></ul>
  40. 44. Treatment of Stable COPD: Inhaled Glucocorticoids <ul><ul><li>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). </li></ul></ul><ul><ul><li>An inhaled glucocorticosteroid combined with a long-acting ß2-agonist is more effective than the individual components (Evidence A). </li></ul></ul>
  41. 45. Treatment of Stable COPD Other Medications <ul><ul><li>Chronic oral Prednisone </li></ul></ul><ul><ul><ul><li>Use in chronic COPD is controversial. No effect on survival. May improve symptoms and reduce hospitalizations in some patients already at maximum treatment </li></ul></ul></ul><ul><ul><li>Mucolytics & Expectorants (SSKI, guafenesin) </li></ul></ul><ul><ul><ul><li>Relives symptoms from copious, viscous secretions </li></ul></ul></ul><ul><ul><li>Oral Theophylline </li></ul></ul><ul><ul><ul><li>If inhalers not sufficient </li></ul></ul></ul><ul><ul><ul><li>Side effects common </li></ul></ul></ul>
  42. 46. Treatment of Stable COPD: Home Oxygen Therapy <ul><ul><li>> 15 hours/day reduces mortality </li></ul></ul><ul><ul><li>Criteria for O2 therapy </li></ul></ul><ul><ul><ul><li>Pa O2 < 55 mm Hg (O2 saturation < 88%) at rest or during exercise or sleep or </li></ul></ul></ul><ul><ul><ul><li>Pa O2 < 60 mm Hg and hematocrit >52% </li></ul></ul></ul><ul><ul><li>Bipap when sleeping may provide additional improvement </li></ul></ul>
  43. 47. Treatment of Stable COPD: Pulmonary Rehabilitation and Patient Education <ul><ul><li>Typically includes exercise, education and psychological support </li></ul></ul><ul><ul><li>Shown to improve symptoms, exercise capacity, reduce use of medical care, reduce anxiety and depression </li></ul></ul>
  44. 48. Treatment of Stable COPD: Surgery <ul><ul><li>Primarily for patients with emphysema </li></ul></ul><ul><ul><li>Few RCTs, no evidence for improvement in mortality but can relieve symptoms </li></ul></ul><ul><ul><li>Improves QOL and exercise capacity in patients with primarily upper lobe disease, low exercise capacity, and FEV1 between 20 and 30% </li></ul></ul><ul><ul><li>Lung transplantation </li></ul></ul>
  45. 49. Treatment of Acute Exacerbations of COPD
  46. 50. Acute Exacerbations of COPD <ul><ul><li>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. </li></ul></ul>
  47. 51. Outpatient Treatment of Acute Exacerbations: Bronchodilators <ul><ul><li>Inhaled bronchodilators (particularly inhaled ß 2 -agonists with or without anticholinergics) are effective treatment for exacerbations of COPD ( LOE: A ). </li></ul></ul>
  48. 52. Outpatient Treatment of Acute Exacerbations: Prednisone <ul><ul><li>Oral prednisone is effective treatment for exacerbations of COPD (LOE: A). </li></ul></ul>
  49. 53. Outpatient Treatment of COPD Exacerbation: Antibiotics <ul><ul><li>Surprisingly little evidence of efficacy </li></ul></ul><ul><ul><li>Typically use in patients with purulent sputum or other signs of infection </li></ul></ul><ul><ul><li>Amoxicillin, doxycycline, azithromycin, trimethoprim-sulfa are reasonable first line choices </li></ul></ul>
  50. 54. Indications for Hospital Admission of Patient with Acute Exacerbation <ul><ul><li>Resting dyspnea after initial treatment </li></ul></ul><ul><ul><li>Lack of response to initial treatment </li></ul></ul><ul><ul><li>Significant co-morbid conditions) </li></ul></ul><ul><ul><li>Severe underlying COPD/prior ICU ventilation for exacerbations </li></ul></ul><ul><ul><li>New physical signs (e.g., new peripheral edema) </li></ul></ul><ul><ul><li>Diagnostic uncertainty </li></ul></ul><ul><ul><li>Insufficient home support </li></ul></ul>
  51. 55. Inpatient Treatment of Acute Exacerbations <ul><ul><li>Oxygen to keep O2 sat >90% </li></ul></ul><ul><ul><li>Nebulizer treatments with bronchodilators </li></ul></ul><ul><ul><li>Steroids (LOE A) </li></ul></ul><ul><ul><ul><li>(40 to 60 mg daily for 7 to 14 days, IV or PO) </li></ul></ul></ul><ul><ul><li>Antibiotics (LOE B)– </li></ul></ul><ul><ul><ul><li>Typically ceftriaxzone (1 gram IV q 24 h) + doxycycline (100 mg po q 12 h) at SFGH </li></ul></ul></ul><ul><ul><li>Fluids </li></ul></ul>
  52. 56. The End Thank you