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COPD/ASTHMA

COPD/ASTHMA. Fernando Catalan Kelly Carew Tom Moran. COPD. WHO on COPD. Today 12 th commonest cause of morbidity 4 th commonest cause of death worldwide By 2020 5th most common cause of morbidity 3 rd most common cause of death. What is COPD. Differential Diagnosis.

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COPD/ASTHMA

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  1. COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

  2. COPD

  3. WHO on COPD Today • 12th commonest cause of morbidity • 4th commonest cause of death worldwide By 2020 • 5th most common cause of morbidity • 3rd most common cause of death

  4. What is COPD

  5. Differential Diagnosis

  6. COPD Classic findings • AP diameter of chest • diaphragmatic excursion • Wheezing • Prolonged expiratory phase Less classic findings: • Max laryngeal height of < 4cm on inspiration • Dyspnea on exertion • Cigarette smoking • Most pts at least 40 yrs old

  7. Studies • Pulmonary Function Testing (PFT) • FEV1 – Air expelled in 1 second • FVC – Forced Vital Capacity – total amount of air that can be taken into the lung • Results- based on PREDICTED values of a healthy standardized population • If FEV1/FVC ratio is less than 70% of the predicted  pt has COPD

  8. Spirometry

  9. Staging of COPD, GOLD criteria • FEV1/FVC < 70% for all stages of COPD • Mild: FEV1 predicted ≥ 80%; pt unaware of lung function decline • Moderate: FEV1 btw 50 & 80%, SOB on exertion • Severe: FEV1 btw 30 & 50%, SOB becomes worse and COPD exacerbations are common • Very Severe: FEV1 < 30%, quality of life is gravely impaired. COPD exacerbations can be life threatening

  10. Chest Radiograph

  11. Management • Bronchodilators Short/Long acting: albuterol/salmeterol • Anticholinergics : Ipratropium, tiotropium • Inhaled glucocorticoids • Systemic glucocorticoids • Smoking cessation: Ask Advice Asses Assist Arrange • Update immunizations: Influenza & Pneumococcal polysaccharide • Educate about COPD exacerbations

  12. Smoking cessation

  13. COPD Exacerbations • Cardinal signs of COPD Exacerbations • Dyspnea Sputum volume Sputum purulence • Inhaled bronchodilators • Oral glucocorticosteroids • Antibiotics • Non-invasive mechanical ventilation • Medication and education on prevention

  14. Summary • COPD: >40yrs old, smoker, dypnea, laryngeal height < 4cm on expiration • PFT: FEV1/FVC < 70%, FEV1: 80/50/30 • Treatment: • All pts with symptoms:Short or Long acting bronchodilator • Combination medications work better than high doses of one medication

  15. Mr. Smith is a 58 yo male who presented with dyspnea on exhertion, productive cough of whitish sputum, with a 40 pack-year of smoking, physical exam reveals increased AP diameter, laryngeal height 2 cm above the sternal notch, and expiratory wheezing -- Which of the following is the best next step in diagnosis? Select the ONE best answer. A       Serum creatinine B       Pulmonary angiogram C       Stress echocardiogram D       Pulmonary function testing E       Chest CT F       Chest radiography

  16. The correct answer is D.Pulmonary function testing (PFT) is the gold standard for diagnosing COPD. It is also the best screening tool for COPD, as it is sensitive enough to detect COPD in its early stages, long before disabling effects are apparent. It should, therefore, be used to confirm the presence of the disease in any patient thought to be at risk of COPD.  In pulmonary function testing, either a FEV1/FVC ratio less than the 5th percentile, or less than 70% predicted, confirms a diagnosis of COPD.  On the next card, we will have a more in-depth explanation of PFTs.Serum creatinine is helpful for diagnosing renal insufficiency.A pulmonary angiogram, although a risky and expensive procedure, serves as the gold standard for diagnosing pulmonary embolism, not COPD.A stress echocardiogram can confirm cardiac ischemia.A chest CT could diagnose cancer. Chest CT often serves as a reasonable gold standard for diagnosing pulmonary embolism, because pulmonary angiography is so risky. • Chest radiographs are seldom diagnostic in COPD.  Radiographic findings are usually more suggestive of advanced COPD, including: hyperinflation (flattened diaphragm on lateral chest film and increased volume of retrosternal air space), hyperlucency of the lungs, and rapid tapering of the vascular markings.

  17. Asthma

  18. Asthma • Inflammatory hyperreactivity of the respiratory tree to various stimuli • Reversible airway obstruction • Mucosal inflammation, bronchial muscular constriction, excessive secretion of viscous mucous causing mucous plugs • Occurs in episodic pattern with interspersed normal airway tone • Seen at any age, usually in young persons

  19. Asthma: Etiology Intrinsic (idiosyncratic) asthma • Occurs in 50% of asthmatics who are nonatopic • Triggers: nonimmunologic stimuli, such as infections, irritating inhalants, cold air, exercise, emotional upset • Attacks are severe, prognosis is less favorable

  20. Etiology Extrinsic (allergic, atopic) asthma • Sensitization: precipitated by allergens • IgE produced • Accounts for 20% of asthmatics • Other symptoms: allergic rhinitis, urticaria, eczema • Prognosis is good

  21. Etiology Aspirin Sensitivity-Nasal Polyposis Syndrome • Affects adults; prevalence is ~10% • Usually starts with perennial vasomotor rhinitis; later, minimal ingestion of aspirin elicits asthma • Cross-reactivity between aspirin and NSAIDS • Desensitization by daily administration of aspirin • Mechanism: chronic overexcretion of leukotrienes, which activate mast cells

  22. Pathophysiology • Narrowing of airways caused by • Hypertrophy and spasm of bronchial smooth muscle • Edema and inflammation of the bronchial mucosa • Production of viscous mucous • Histamine, bradykinin, leukotrienes, prostaglandins • Bronchoconstriction and vascular congestion • Mast cells, lymphocytes, and eosinophils

  23. Asthma Severity Classification • Mild Intermittent asthma: symptoms twice a week or less, bothered by symptoms at night twice a month or less. • Mild persistent asthma: symptoms more than twice a week, but no more than once in a single day, bothered by symptoms at night more than twice a month. • Moderate persistent asthma: symptoms every day, bothered by nighttime symptoms more than once a week. • Severe persistent asthma: symptoms throughout the day on most days, bothered by nighttime symptoms often.

  24. DIAGNOSIS Clinical History Physical exam HEENT – general allergy symptoms Lungs – Expiratory wheezes, Decreased I/E ratio. Skin – atopic dermatitis

  25. DIAGNOSIS • Pulmonary Function Testing FEV1-This is the volume of air expired in the first second during maximal expiratory effort FVC-total volume of air expired after a full inspiration. • CBC: eosinophilia • CXR: Hyperinflation

  26. Spirometry

  27. Peak Flow Meter

  28. Assessing an Asthma Attack • Distress? • Distinguishing the severity by PEF or FEV1 • >50% of predicted is mild to moderate • <50% of predicted is severe • ABG • Initially low pCO2 • Eventually elevated pCO2

  29. TREATMENT Relief meds Acute relief from symptoms Preventers anti-inflammatory Controllers Have sustained bronchodilation effects, but anti-inflammatory action is unproven

  30. Treatment - Relievers 1) Short-acting Beta2 agonists (albuterol) 2) Anticholinergics (Ipratropium bromide)

  31. TREATMENT - Preventers 1)Inhaled corticosteroids 2) Cromones (Cromolyn and nedocromil)

  32. TREATMENT - Controllers 1) Long acting Beta2 agonists (Salmeterol andFormoterol) 2) Methylxanthines (Theophylline) 3) Leukotrieneantagonists (Zafirlukast and Montelukast) (Zileuton)

  33. Treatment

  34. PATIENT EDUCATION Asthma Action Plan 1) obtain a personal best PEF 2) Chart Green, yellow, red Green – 80-100% of personal best PEF Yellow – 50-80% Red - <50%

  35. Question A 24yo AAF presents at your primary care office with a slightly elevated temperature, and headache. She has a PMH significant for severe asthma. Physical shows a decreased inspiratory/expiratory ratio as well as nasal polyps. What recommendations concerning antipyretic and analgesic use are important to convey before the pt leaves the office? • A) Administer only acetaminophen for fever and discomfort. • B) Administer ibuprophen q6 for 48 hrs.  • C) Administer Motrin for q6 for 48 hrs.  • D) Administer only NSAIDs for fever and discomfort.

  36. Answer A 24yo AAF presents at your primary care office with a slightly elevated temperature, and headache. She has a PMH significant for severe asthma. Physical shows a decreased inspiratory/expiratory ratio as well as nasal polyps. What recommendations concerning antipyretic and analgesic use are important to convey before the pt leaves the office? • A) Administer only acetaminophen for fever and discomfort. In about 25% of pts with asthma, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can precipitate an asthma attack and should be avoided.

  37. References • Cooper, D. Krainik, A. Lubner, S. Reno, H. Washington Manual or Medical Therapeutics. 2007 • Boon, N. Colledge, N. Walkder, B. Davidson’s principles and practice of med. 2008. • Global Initiative for Chronic Obstructive Lung Disease. http://www.goldcopd.com Last accessed 6/15/2010. • U.S. Dept. of Health and Human Services. Task Force Recommends Against Screening for Chronic Obstructive Pulmonary Disease Using Spirometry. Press Release, March 3, 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/press/pr2008/tfcopdpr.htm Last accessed 6/12/10. • U.S. Preventive Services Task Force. Screening for Chronic Obstructive Pulmonary Disease Using Spirometry, Topic Page. March 2008. .  Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspscopd.htm  Last accessed 6/12/10. • Ferri, Fred. Practical guide to The care of the Medical Patient, 7th ed. Pensilvania, Elsevier, 2007, pp 777-779. • Global Initiative for Chronic Obstructive Lung Disease, Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD, 2008, accessible at www.goldcopd.com. Last accessed 7/28/2010.

  38. Additional Resources on COPD • Global Initiative for Chronic Obstructive Lung Disease. http://www.goldcopd.com Last accessed 6/15/2010.U.S. Dept. of Health and Human Services. Task Force Recommends Against Screening for Chronic Obstructive Pulmonary Disease Using Spirometry. Press Release, March 3, 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/press/pr2008/tfcopdpr.htm Last accessed 6/12/10.U.S. Preventive Services Task Force. Screening for Chronic Obstructive Pulmonary Disease Using Spirometry, Topic Page. March 2008. .  Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspscopd.htm  Last accessed 6/12/10. • Global Initiative for Chronic Obstructive Lung Disease, Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD, 2008, accessible at www.goldcopd.com. Last accessed 7/28/2010.

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