Download COPD - HomeCare Association of Arkansas

Stan Kellar, MD
Chief of Clinical Affairs, BH NLR
Pulmonary Medicine
Sleep Medicine
COPD
Physiology
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The lungs are filters
Filter in oxygen
Filter out carbon dioxide
(Vascular filter, not part of this discussion)
Physiology
• Ventilation
• Perfusion
• Diffusion
Anatomy
Inspiration/Expiration
INSPIRATION
Passive Expiration
Forced Expiration
Respiratory bronchiole
Tethering
Normal Conducting System
Alveoli
• Surface area equivalent to that of a tennis
court.
• Very thin.
Alveolar and capillary surface
Perfusion
• Low pressure bed, PA pressure 30/10.
• Approximately 6 billion capillaries in human
lung, or about 2000 per alveolus.
• Under normal (resting) conditions there is
little or no flow to the apices, a waterfall
effect.
Ventilation/Perfusion
• Under normal circumstances the V/Q
(ventilation to perfusion) ratio is 1.
• This is altered with decreased perfusion (PE)
or decreased ventilation (obstructive lung
disease or infiltrative diseases).
Transportation O2
• Primarily by hemoglobulin.
• Very little dissolved in plasma.
Transportation of CO2
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10% dissolved in plasma.
20 % carried by Hemoglobin.
70% in form of bicarbonate.
CO2 dissociation curve linear.
COPD
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Chronic airflow limitation
Airway inflammation
Affects more than 6% of the population
Third leading cause of death in US
Preventable
Treatable
COPD
• Chronic bronchitis-chronic productive cough
for three months in two successive years
• Emphysema-permanent enlargement of
airspaces distal to the terminal bronchioles,
loss of alveolar walls
• “Asthma”-Reversible airflow limitation
Emphysema
Causes
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Smoking-Duration and Amount. PACK YEARS
Threshold? About 25 pack years
Smoking
Smoking
Biomass fuel in developing countries
Incidence
• Overall 6.3% USA
• Higher in men, lower education level and
socioeconomic groups
• Incidence increases with increasing age
• 3rd to 6th leading cause of death
RISK BY AGE
Pathology
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Airway limitation-inflammation
Goblet cell hyperplasia
Mucus plugging
Loss of airway tethering
Loss of airway rigidity
Bronchospasm
Normal Airway
Airway narrowing
Symptoms
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Shortness of breath
Cough, with or without sputum
Wheezing
Chest tightness
Dyspnea
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Lung disease
Heart disease
Circulatory problems
Neuromuscular diseases
Therefore not all dyspnea is due to lung
diseases
Wild Cards
• ACID REFLUX
• 25% of patients with significant reflux have no
reflux symptoms
• Another 25% underestimate the degree of
reflux
• Patients with symptoms have 2x rate of
exacerbations
• Deconditioning
Physical Findings
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Wheezing
Decreased breath sounds
Crackles in bases
Diminished heart sounds
Barrel-shaped chest
Tobacco stained finger tips
Clubbing is rare
Chest X-ray
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Normal
Hyperinflation
Bullae
Flattened hemi-diaphragms
Basilar scarring
Unexpected disease-pneumothorax, lung
cancer
Hyperinflation
Pneumothorax
Spirometry
• FEV1-effort dependent
• FVC-effort and time dependent, more than 6
seconds
• FEV1/FVC ratio-less than 70%
• Peak flow-useful for trends, very effort
dependent
Global initiative on chronic Obstructive Lung
Disease
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GOLD 1: Mild (FEV1 >80% Pred.)
GOLD 2: Moderate (FEV1 50-80% Pred.)
GOLD 3: Severe (FEV1 30-50% Pred.)
GOLD 4: Very severe (FEV1 < 30% Pred.)
COPD Assessment Test
OK < 10
Modified Medical Research Council Guide
• Please Check Line That Applies to You
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Grade 0: I only get short of breath with strenuous exercise.
Grade 1: Short of breath hurrying or up slight incline.
Grade 2: I walk slower on level ground as similar aged individuals
or I stop to rest when walking on my own.
Grade 3: I stop for breath when walking 100 meters or after a
few minutes.
Grade 4: I am too breathless to leave the house or I am
breathless dressing or undressing.
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RISK
• Related to history of exacerbations
• Group A: Low risk, less symptoms - GOLD 1-2
and 0-1 exacerbations
• Group B: Low risk, More symptoms – GOLD 12 and 0-1 exacerbations
• Group C: High risk, Less symptoms – GOLD 34 and > 2 exacerbations
• Group D: High risk, More symptoms - GOLD 34 and > 2 exacerbations
Exacerbations
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Increased dyspnea
Increased cough
Sputum production
+/- fever
+/- chest pain – chest tightness
Median time between onset of symptoms and
onset of treatment 3.69 days
Exacerbation Treatment
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Steroids, oral or IV
Antibiotics, oral or IV
Additional bronchodialators
Hospitalization
Non-invasive ventilation
Ventilation
Over 7% do not return to baseline
Hospitalization
• Mortality > 10%
• Only 75% recover to recent baseline at 5
weeks
• 7% have not recovered baseline at 3 months
• 63% readmitted during following year
• Represents 40-60% of overall cost of care
Hospitalization
• Immobilization
• Sedation
• Hospital acquired conditions
• Fragmentation of care – Medication
reconciliation – cost of medications – followup
• Depression - anxiety
Hospital at Home
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Population health strategy
Competent caregiver available
In a contained geographic area
Dedicated team of doctor(s), nurses, etc.
Daily visits, possibly including phone or
telemedicine visits
• Limited care time frame < 15 days
Smoking Cessation
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Without help/nicotine replacement-10%
With help/nicotine replacement-50-60%
ASK – ADVISE – ASSESS – ASSIST- ARRANGE
Chantix
Nicotine, Give enough
Too much nicotine causes nausea
Decreased airflow + smoking
• Progressive lung disease
• 25 times normal risk for heart attack or stroke
• 8 times risk for lung, laryngeal, esophageal,
stomach, kidney, bladder, oral and pancreatic
cancer
• Cessation rapidly reduces the risk of
cardiovascular complications
Medications: Short acting
Rescue
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Beta agonists, MDI or nebulizer (albuterol)
Techniques
Spacers
Cost
Intended for rescue
Primary side effects cardiac arrhythmia
(tachycardia) and tremor
Medications: Short acting
Rescue
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Anticholinergics, MDI or nebulizer (Atrovent)
Short acting
Rescue
Costs
Adverse effects rare, dryness
Medications: Long acting
• Beta agonists, MDI and nebulizer
• Foradil and Serevent are the primary single
agents with MDI
• Perforomist and Brovana are the nebulized
forms
• Almost never used alone
• Increased risk of death in asthma patients
when use alone (Black Box Warning)
Medications: Long acting
• Anticholinergics, MDI
• Spiriva and Tudorza
• Cost
Medications: Inhaled Steroids
• MDI and nebulizer
• Controversy
• Single agents, Flovent, Asmanex, Qvar,
Pulmicort
• Anti-inflammatory
• Adverse effects-oral thrush, hoarseness,
possible osteoporosis, increased risk of
pneumonia
Medications: Steroids/Beta agonists
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MDIs
Advair Discus and MDI
Symbicort
Dulera
Breo, new, fluticasone and vilanterol
Medication: LABA + LA Anticholinergic
• Anoro, new
Medications: Steroids
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Anti-inflammatory
Oral prednisone or Medrol
Dose and length of treatment controversial
IV for hospitalized patients, dose and length of
treatment controversial
• Adverse effects – Hyperglycemia, thrush,
increased risk of infection, osteoporosis,
weight gain, myopathy
Medications: Phosphodiesterase-4 Inhibitors
• Daliresp – anti-inflammatory
• Frequent side effects with nausea, vomiting,
diarrhea, generalized aches, loss of appetite
Medication: Theophyllins
• Moderate bronchodialator
• Toxicity is dose related
• Adverse effects – nausea, vomiting,
headaches, seizures
• Blood levels altered by other medications,
both up and down
Special Consideration
• Alpha-1 Antrypsin Deficiency
• Earlier emphysema with a basilar
predominance
• Replacement available
• Testing is free
Vaccinations
• Yearly flu immunization
• Pneumococcal vaccine for patients 65 years
and older
Oxygen
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Improve mortality
Improve dyspnea
Improve quality of life
Improve cognition
Cost – over $500/mo., 1 million patients in
USA at a cost of over 2 billion dollars
Oxygen
• PaO2 , 55 mmHg or saturation, 89% at rest
• PaO2 , 60 with cor pulmonale, right heart
failure or HCT > 55
• O2 saturation less than 89 % for more than 5
minutes with sleep (Look for OSA)
• Pao2 < 55 or saturation <88 with exercise
• In COPD patients check ABGs on O2 to check
PaCO2
ANN Internal Med 1980; 93:391
Lancett 11981; 1:681
Oxygen
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No benefit for saturations > 92%
Increase in PaCO2 (Hypoventilation)
Absorptive atelectasis
Hyper-oxemia can result in decreased free water
clearance
• Facial burns especially in patients with facial hair
• Fall risk with the tubing
• NO SMOKING
RISK
• Related to history of exacerbations
• Group A: Low risk, less symptoms - GOLD 1-2
and 0-1 exacerbations
• Group B: Low risk, More symptoms – GOLD 12 and 0-1 exacerbations
• Group C: High risk, Less symptoms – GOLD 34 and > 2 exacerbations
• Group D: High risk, More symptoms - GOLD 34 and > 2 exacerbations
Treatment Recommendations
GOLD
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Group A
Group B
Group C
Group D
• Group A
• Group B
• Group C
• Group D
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S-A Beta agonist or anticholinergic
L-A Beta agonist or anticholinergic
ICS + LA Beta or LA anticholinergic
ICS + LA Beta +/or LA anticholinergic
ALTRERNATIVE
LA Beta or LA anticholinergic or SA Beta
with SA anticholinergic
• LA Beta with LA anticholinergic
• LA Beta + LA anticholinergic or LA Beta +
PD4 Inh or LA anticholinergic + PD4 Inh
• ICS + LA Beta + LA Antichol. Or ICS + LA Beta
+ PD4 Inh, or LA Beta + LA antichol, LA
antichol + PD4 inh
Other Considerations
• Exercise
• Mucolytics
• Antidepressants
Comorbidities
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Coronary artery disease
Osteoporosis
Peripheral vascular disease
Cancer
Heart failure
Atrial fibrilation
Interstitial lung diseases
Chronic Care Management
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Self Management Strategies
Clinical Information Systems
Delivery System Design
Decision Support
Community Resources
Self Management Strategies
• Education-Behavioral support-Motivational support –
to promote behavioral changes:
• 1. Improved medication adherence.
• 2. Smoking cessation.
• 3. Vaccinations.
• 4. Regular bronchodialator use.
• 5. Proper inhaler technique.
• 6.Regular exercise.
• 7.Supplemental Oxygen use.
• 8. Increased physical activity in the home.
• 9. Early reporting of exacerbations.
Referrences
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Global Initiative for Chronic Obstructive lung Disease
Lancet 370; 2007, p741, “International variation…”
Lancet 378; 2011, p991, “Lifetime risk…”
MMWR 61, 2012, p938, “COPD among adults”
UpToDate
Chest 130; 2006, p1096, “Role of gastroesophageal…”
Am J Crit Care Med 180; 2009, p3, “The Natural History…”
NEJM 365: 2011, p1184, “Changes in Forced…”
Pulmonary Physiology in Clinical Medicine, Tisi
Am J Respir Crit Care Med 161; 2000, p 1608, “Time course and recovery…”
BMJ 1; 1977, p1645, “The natural history…”
Am J Respir Crit Care Med178; 2008, p332, “Effect of pharmacotherapy…”
JAMA 309;2013, p2223, “Short-term vs conventional…”
Eur Respir J; 2009: 507-512. “ Discharge Planning and home care…”
References, cont.
• Proc Am Thor Soc; 9 (1):9-18. “Integrated care of
the COPD patient”
• International J of COPD 2011; 6: 605-614.
“Implementing chronic care for COPD…”
• Arch Int Med 2007; 167: 551-561. “Systematic
Review of the Chronic Care Model in COPD…”
• Health Affairs 2001; 20 (6):64-78. “Improving
Chronic illness care…”
• Am J Crit Care Med 2004; 169: 1298-1303. “Early
Thearpy improves outcomes…”