ryan martin, md nebraska pulmonary specialties - …
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COPDDiagnosis, Management and ProgramRYAN MARTIN, MDNEBRASKA PULMONARY SPECIALTIES
Initial diagnosis
Setting matters: Inpatient. Usually sicker, oftentimes avoiding healthcare.
Outpatient. Often seeking treatment before significant decompensation
Symptoms Cough
Sputum production
Shortness of breath
Cyanosis
Hypoxia.
WheezingClubbing
Diagnosis
Setting matters… Outpatient
Symptom assessment
CXR – usually shows hyperinflation and more translucent lung fields, flattened diaphragm.
PFTs – Show obstructive pattern. Severity varies. DLCO may be altered.
ABG May show either hypoxia, hypercapnia, both or neither
Alternate diagnosis?
Elevated total CO2 on BMP
Polycythemia
1. Hyperinflation.2. Hyperlucency3. Increased
retrocardiacairspace
4. Diaphragmatic flattening
Vs NORMAL.
Diagnosis
Inpatient. Usually arrive during acute exacerbation. Many of the above findings are present. Often times more prevalent
even.
Stage of disease is not determinate during the acute exacerbation
ABGs are usually worse acutely.
I avoid doing complete PFTs during acute exacerbation. Spiro or peak flow give enough information.
Cyanosis and hypoxia may be initially present, often reverse with treatment.
CXR findings are usually not appreciably different from acute to chronic settings
Obstructive PFTs. Above the X axis is EXPIRATION,
below it is INSPIRATION Dotted line indicates the expected
expiratory flow limb. COPD/Asthma will have the typical
spike, but then the obstruction takes over
Pursed lip breathing will move the obstruction to the more proximal part of the airway (Mouth) and help stent the smaller, distal airways open.
Reference ranges
Very important to PFT interpretation Determinants are Age, Gender and
Height. Ethnicity plays a smaller role
ABG
7.40/40/90/24 is the normal pH / PCO2 / PO2 / Bicarb Numbers can change both acutely AND chronically. Look to the pH to help direct your acuity.
COPD
It, at cellular level, is the destruction of the alveoli This includes loss of capillaries (where O2 and CO2 exchange occur) Predominantly caused by inhalation. Hyperinflation occurs due to loss of multiple alveoli As the lung becomes over-inflated, the airways become more
collapsible. Forced expiration will exacerbate wheezing.
GOLD 2017
Stages 1-4 derived by FEV1 Classes ABCD are combination based upon the :
Stage + Symptoms.
GOLD A is Stage 1 or 2 without exacerbations
GOLD B is Stage 1 or 2 WITH exacerbation
GOLD C is Stage 3 or 4 without exacerbations
GOLD D is Stage 3 or 4 WITH exacerbations
Treatment
Mainstays of therapy are derived by severity Can be as simple as Albuterol alone/as needed. Most commonly people use 1-2 daily inhalers PLUS a rescue inhaler. Our practice uses the 2017 GOLD guidelines LAMA/LABA preferred medication (for initial start of medication) LAMA/LABA/ICS (for Frequent Exacerbations) PDE inhibitors (Daliresp and Theophylline) Antibiotics (occasionally in Severe patients) Steroids
New DataIMPACT trial
GSK funded study that did a 3 arm trial Focused on the EXACERBATING patient. The arms are
1. Fluticasone/Vilanterol (LAMA/LABA class)
2. Umeclidinium/Vilanterol
3. Fluticasone/Umeclidinium/Vilanterol
Results showing that in the multiple exacerbating patients, triple therapy was most successful
PDE inhibitors
Falls into the classification of Daliresp specifically. Major SE is the GI distress/upset.
Typically lasts about 1 week
New starter pack that uses smaller dose.
Take a week off.
Not suited for all COPD’ers Typically the patients with Chronic Bronchitis
Acute Management of the Exacerbating Patient.
Nebulized medicaitons available and routinely used include Brovana (Afomoterol) or Perforomist (Afomoterol) Pulmicort (Budesonide) Xopenex (Levalbuterol Duonebs (Ipratropium and Albuterol) Albuterol Atrovent (Ipratropium) Lonhala
Acute Management of the Exacerbating Patient.
Steroids Oral meds
Prednisone
IV meds Solu-Medrol (methylprednisolone)
Antibiotics. Do not often require CAP or HCAP coverage.
Acute Management of the Exacerbating Patient.
Antibiotics Selection depends on comorbid conditions
Bronchiectasis
Concurrent PNA
Recent hospitalizations.
Allergies
Immune status
GOLD guidelines update
Transitioned to a LAMA/LABA for initial start of COPD GOLD 2 and 3
Bevespi, Anoro, Stiolto and Utibron
LAMA/LABA/ICS reserved for the more severe categories GOLD 4, or c/d
Trelegy
Some Combination of LABA/ICS + LAMA
Device decisions
Inhalers/MDI require typically about 30cc/sec to get medication delivery to the smaller airway where the mechanism of action can be achieved.
Hand-eye coordination matters. MDI vs Elipta vs Respimat device.
Activity level Extremely poor inspiratory capacity
should dictate usage of NEBs.
Program for Preventing Readmissions
Centers around Transition of care from Acute to Chronic. Withdrawal of acute therapies to something that can be readily
delivered at home. Devices such as Non-Invasive ventilation (BIPAP) can be life-saving
in the hospital but may not always have a role as an outpatient. Nebulized therapy IV medications
Program for Preventing Readmissions
Medication reconciliation is probably the single most important step Medication cost analysis Follow up appointment Home Health Care Durable medical equipment Pulmonary rehab Sleep disorders
Program for Preventing Readmissions
Constant self assessment. Routine analysis of data Iterative process to evaluate which steps are troublesome for
patients Predictive analysis of our patient population.
PNA, CHF, Aspiration and Hypercapnia predict readmission.
Oxygen Assessments
Walking Oximetry is indicated when the DLCO drops below 55% predicted.
6MWT is better used in Prognostic implications High Altitude Simulation Testing can be done if patients concerned.
Rule of thumb is if Dx of COPD/ILD and has exertional dyspnea, I would do one prior to significant elevation exposure…>2 hours.
Lung Cancer Screening
Lung Cancer Screening Must be done at a screening center/registry Annual lung cancer screening CTs even if negative initial scan Simplest minimum requirements:
30 pack years
Over the age 55, under the age of 80
Must have been a daily smoker within the last 15 years.
CT Lung Cancer Screening
False positive rate may be as high as 97% New Fleischner Society guidelines for follow up of the pulmonary
nodule Less concern for nodules < 6mm Ground glass lesions require longer follow up. Majority of the false positive tests simply end up as ongoing
monitoring with LD CTs.
Cases
82 yo male, retired farmer 55 pack years history, quit in 2009 Exertional dyspnea, Wheezing. CXR with hyperinflation, no evidence of nodule FEV1 58% predicted, FVC 89% predicted. No Sputum No weight loss Never hospitalized. Annual flu shot, has had Pneumovax.