copd/asthma fernando catalan kelly carew tom moran
TRANSCRIPT
COPD/ASTHMA
Fernando Catalan
Kelly Carew
Tom Moran
COPD
WHO on COPD
Today12th commonest cause of morbidity4th commonest cause of death worldwide
By 2020 5th most common cause of morbidity3rd most common cause of death
What is COPD
Differential Diagnosis
COPD Classic findings
AP diameter of chest diaphragmatic excursionWheezingProlonged expiratory phase
Less classic findings: Max laryngeal height of < 4cm on inspiration Dyspnea on exertion Cigarette smoking Most pts at least 40 yrs old
Studies
Pulmonary Function Testing (PFT)FEV1 – Air expelled in 1 secondFVC – Forced Vital Capacity – total amount of
air that can be taken into the lungResults- based on PREDICTED values of a
healthy standardized population If FEV1/FVC ratio is less than 70% of the
predicted pt has COPD
Spirometry
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
Chest Radiograph
Management
Bronchodilators Short/Long acting: albuterol/salmeterolAnticholinergics : Ipratropium, tiotropium
Inhaled glucocorticoidsSystemic glucocorticoids
Smoking cessation: Ask Advice Asses Assist Arrange
Update immunizations: Influenza & Pneumococcal polysaccharide
Educate about COPD exacerbations
Smoking cessation
COPD Exacerbations
Cardinal signs of COPD ExacerbationsDyspnea Sputum volume Sputum purulence
Inhaled bronchodilatorsOral glucocorticosteroids AntibioticsNon-invasive mechanical ventilationMedication and education on prevention
Summary
COPD: >40yrs old, smoker, dypnea, laryngeal height < 4cm on expiration
PFT: FEV1/FVC < 70%, FEV1: 80/50/30Treatment:
All pts with symptoms:Short or Long acting bronchodilator
Combination medications work better than high doses of one medication
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
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.
Asthma
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
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
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
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
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
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.
DIAGNOSIS
Clinical
History
Physical exam
HEENT – general allergy symptoms
Lungs – Expiratory wheezes, Decreased I/E ratio.
Skin – atopic dermatitis
DIAGNOSIS
Pulmonary Function TestingFEV1-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: eosinophiliaCXR: Hyperinflation
Spirometry
Peak Flow Meter
Assessing an Asthma Attack
1) Distress?
2) Distinguishing the severity by PEF or FEV1
a. >50% of predicted is mild to moderate
b. <50% of predicted is severe
3) ABG a. Initially low pCO2
b. Eventually elevated pCO2
TREATMENT
Relief meds
Acute relief from symptoms
Preventers
anti-inflammatory
Controllers
Have sustained bronchodilation effects, but anti-inflammatory action is unproven
Treatment - Relievers
1) Short-acting Beta2 agonists
(albuterol)
2) Anticholinergics
(Ipratropium bromide)
TREATMENT - Preventers
1)Inhaled corticosteroids
2) Cromones
(Cromolyn and nedocromil)
TREATMENT - Controllers
1) Long acting Beta2 agonists
(Salmeterol andFormoterol)
2) Methylxanthines
(Theophylline)
3) Leukotrieneantagonists
(Zafirlukast and Montelukast)
(Zileuton)
Classification Severity of Sx. NightimeSx FEV Treatment
Mild Intermittent
Sx<2x/wk, otherwise asymptomatic
Sx<= 2x/mo >80% Beta 2 agonist
Mild Persistent Sx> 2x/wk, <1x/day
Sx>=2x/mo >80%variability from 20-30%
1)Low-dose ICS2)Cromolyn3) Leukotriene Antagonist
Moderate Persistent
DailySx, Daily use of beta2 agonist
Sx>=1x/wk 60% - 80% 1) Medium dose ICS
2) Long acting B2 agonist
Severe Persistent
Continual Sx. Frequent <60% 1) High dose ICS
2) Long acting B2 agonist
Treatment
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%
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.
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.
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.
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.