copd/asthma fernando catalan kelly carew tom moran

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COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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Page 1: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

COPD/ASTHMA

Fernando Catalan

Kelly Carew

Tom Moran

Page 2: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

COPD

Page 3: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 4: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

What is COPD

Page 5: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Differential Diagnosis

Page 6: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 7: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 8: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Spirometry

Page 9: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 10: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Chest Radiograph

Page 11: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 12: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Smoking cessation

Page 13: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

COPD Exacerbations

Cardinal signs of COPD ExacerbationsDyspnea Sputum volume Sputum purulence

Inhaled bronchodilatorsOral glucocorticosteroids AntibioticsNon-invasive mechanical ventilationMedication and education on prevention

Page 14: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 15: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 16: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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.

Page 17: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Asthma

Page 18: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 19: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 20: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 21: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 22: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 23: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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.

Page 24: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

DIAGNOSIS

Clinical

History

Physical exam

HEENT – general allergy symptoms

Lungs – Expiratory wheezes, Decreased I/E ratio.

Skin – atopic dermatitis

Page 25: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 26: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Spirometry

Page 27: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Peak Flow Meter

Page 28: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 29: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

TREATMENT

Relief meds

Acute relief from symptoms

Preventers

anti-inflammatory

Controllers

Have sustained bronchodilation effects, but anti-inflammatory action is unproven

Page 30: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

Treatment - Relievers

1) Short-acting Beta2 agonists

(albuterol)

2) Anticholinergics

(Ipratropium bromide)

Page 31: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

TREATMENT - Preventers

1)Inhaled corticosteroids

2) Cromones

(Cromolyn and nedocromil)

Page 32: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

TREATMENT - Controllers

1) Long acting Beta2 agonists

(Salmeterol andFormoterol)

2) Methylxanthines

(Theophylline)

3) Leukotrieneantagonists

(Zafirlukast and Montelukast)

(Zileuton)

Page 33: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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

Page 34: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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%

Page 35: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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. 

Page 36: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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.

Page 37: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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.

Page 38: COPD/ASTHMA Fernando Catalan Kelly Carew Tom Moran

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.