Download COPD M3 lecture - Creighton University

COPD
M3 lecture
Tammy Wichman MD
Assistant Professor of Medicine
Pulmonary-Critical Care
• A 55 year old male presents to the office with worsening
shortness of breath over the past 6 months. He has a morning
cough productive of thick white sputum. He denies any chest
pain. His weight has been stable. He has a 45 pack year
smoking history and continues to smoke ½ pack per day. He
drinks several beers on the weekends. He is divorced and works
as an engineer. What of the following tests should you order to
work up his dyspnea?
• Pulmonary Function Tests including DLCO
• Chest x-ray
• Spiral CT to rule out chronic thromboembolic disease
• High-resolution CT to evaluate for interstitial fibrosis
• Methacholine challenge
• Allergy Skin Testing
• Pre- and Post-Bronchodilator spirometry
• Arterial blood gas
• 6 minute walk
Diagnosis of COPD
SYMPTOMS
EXPOSURE TO RISK
FACTORS
cough
sputum
dyspnea
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY
Spirometry
• The severity of disease in COPD is assessed by
_________. The classification system is called
________.
• Disease severity ________ (is or is NOT)
associated with mortality.
Deterioration in Lung Function in Patients with COPD
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
Variables and Point Values Used for the Computation of the Body-Mass Index, Degree of Airflow
Obstruction and Dyspnea, and Exercise Capacity (BODE) Index
Celli, B. R. et al. N Engl J Med 2004;350:1005-1012
Kaplan-Meier Survival Curves for the Four Quartiles of the Body-Mass Index, Degree of Airflow
Obstruction and Dyspnea, and Exercise Capacity Index (Panel A) and the Three Stages of
Severity of Chronic Obstructive Pulmonary Disease as Defined by the American Thoracic Society
(Panel B)
Celli, B. R. et al. N Engl J Med 2004;350:1005-1012
Other tests
• Bronchodilator reversibility
– Helpful to rule out a diagnosis of asthma, to establish a patient’s best
attainable lung function, to gauge a patient’s prognosis, and to guide
treatment decisions
– Even patients who do not show a significant FEV1 response to a shortacting bronchodilator test may benefit symptomatically
• CXR-seldom diagnostic unless obvious bullous disease is present
but it is valuable in excluding alternative diagnosis
• ABG-should be measured in patients with FEV1<40% predicted
or with cor pulmonale
• Alpha-1 antitrypsin deficiency: in patients who develop COPD
at a young age or who have a family history
COPD Definition
Fill in the blanks
• Disease state characterized by ____________
that is not fully __________. The
_______________ is usually both progressive
and associated with an abnormal inflammatory
response of the lungs to _______________.
COPD Definition
• Disease state characterized by airflow limitation
that is not fully reversible. The airflow
limitation is usually both progressive and
associated with an abnormal inflammatory
response of the lungs to noxious particles or
gases.
• Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive
Pulmonary Disease www.goldcopd.com
Lancet 2003;362:1053-61
Pathology of COPD
Fill in the boxes
SMOKING
Pathology
Physiologic
Consequence
Large airways
1.
2.
1.
Small airways
1.
2.
3.
1.
1.
Alveoli
1.
Pathology
• What is the single most effective intervention to
stop the progression of COPD in this patient?
• How would you do this? Be specific.
Smoking Cessation
• Single most effective (and cost effective)
intervention to reduce the risk of developing
COPD and stop its progression
• Brief tobacco dependence treatment is effective
and every tobacco user should be offered at least
this treatment at every visit to the health care
provider
Strategies to Help the Patient Willing
to Quit Smoking
• 1. ASK: Systematically identify all tobacco
users at every visit.
• 2. ADVISE: Strongly urge all tobacco users to
quit.
• 3. ASSESS: Determine willingness to make a
quit attempt.
• 4. ASSIST: Aid the patient in quitting
• 5. ARRANGE: Schedule follow-up contact
Pharmacotherapy
• Nicotine replacement reliably increases longterm smoking abstinence rates
• Bupropion and Nortriptyline have been shown
to increase long-term quit rates
Effects of Smoking Cessation on Natural
History of FEV1
FEV1 (Percentage of Value at
Age 25 Years)
100
75
50
Disability
25
Death
† †
0
25
50
75
Age (Years)
Smoked Regularly and Susceptible to Its Effects
Stopped at Age 45 Years
Stopped at Age 65 Years
Never Smoked or not Susceptible to Smoke
Fletcher C, Peto R. Br Med J. 1977;1:1645-1648.
Anthonisen et al. Smoking and lung function of Lung Health Study
participants after 11 years. Am J Respir Crit Care Med 2002;166(5)675-9.
Anthonisen et al. Lung Health Study Research Group. Ann Intern Med 2005;142:233-9
Mortality benefit despite the fact that only 21.7% of smoking intervention
group quit vs 5.4% of usual care group
• A 61 year old female presents to the office with worsening
shortness of breath. Symptoms have been gradually worsening
over the past several years. She has a chronic cough productive
of white sputum. Patient was started on oxygen by her primary
care physician last month and was referred to you for further
evaluation. Her past medical history is significant for
hypertension. She quit smoking several years ago. She drinks
one glass of wine a day. She recently quit her job as a day care
provider. She denies any fever or chills. Her current
medications are:
• VoSpire (Albuterol) ER 8 mg po Q 12 hours
• Atrovent nebulizers Q 6 hours
• Prednisone 10mg po Q day
• Theophylline 200mg po BID
• Inderal (Propranolol) 80 mg po BID
• On exam, T 37.5 HR 82 R 16 BP 135/65 Sats 95% on
2L O2 by nasal cannula. She has a mildly increased P2
on cardiac exam. She has a prolonged expiratory phase
on lung exam with scattered end-expiratory wheezes.
The rest of her exam is normal. Her CXR is available
for review. Her pulmonary function tests are: FVC
1.56 L 59% predicted improving to 1.9 L 72%
predicted, a 22% improvement. FEV1 0.67 36%
predicted improving to 0.92 L a 37% improvement.
TLC 120% predicted. RV 191% predicted and DLCO
38% predicted.
• How would you rate the severity of her disease?
• What adjustments should be made to her medical
regimen?
• Can anything be done to prolong her life?
• Are there any non-medical options available to improve
her condition?
Which of the following are
objectives of COPD management?
•
•
•
•
•
•
•
•
•
•
Prevent disease progression
Improve pulmonary function tests
Relieve symptoms
Repair emphysematous lungs
Improve exercise tolerance
Improve health status
Decrease oxygen requirements
Prevent and treat exacerbations
Reduce mortality
Minimize side effects from treatment
Objectives of COPD Management
•
•
•
•
•
•
•
•
Prevent disease progression
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent and treat exacerbations
Prevent and treat complications
Reduce mortality
Minimize side effects from treatment
Monitor Disease Progression
• COPD is a progressive disease, and a patient’s
lung function can be expected to worsen over
time, even with the best available care
Manage Stable COPD
• Stepwise increase in treatment, depending on the
severity of the disease.
• Patient education improves skills, ability to cope with
illness and health status.
• None of the existing medications for COPD has been
shown to modify the long-term decline in lung
function. So pharmacotherapy is used to decrease
symptoms, reduce the frequency and severity of
exacerbations, improve health status, and improve
exercise tolerance
Manage Stable COPD:
Bronchodilators
• Bronchodilator medications are central to the
symptomatic management of COPD. They are given
on an as-needed basis or on a regular basis to prevent
or reduce symptoms.
–
–
–
–
–
Alleviate symptoms
Improve exercise tolerance
Improve quality of life
Decrease the incidence of exacerbations
Decrease hyperinflation
• Inhaled therapy is preferred
Manage Stable COPD:
Bronchodilators
• Beta2-agonists: increase cyclic adenosine
monophosphate levels and promote airway smoothmuscle relaxation
– Short acting: Albuterol (Proventil)
– Long acting: Salmeterol (Serevent) and
Formoterol fumarate (Foradil)
• Anticholinergics: block muscarinic receptors
– Short acting: Ipratropium bromide (Atrovent)
– Long acting: Tiotropium bromide (Spiriva)
• Combination: (Combivent, DuoNeb)
Manage Stable COPD:
Bronchodilators
• Phosphodiesterase Inhibitors: increase intracellular
cyclic adenosine monophosphate levels within airway
smooth muscle
– 3rd line agent
– Improves respiratory muscle function, stimulates the
respiratory center, decreases dyspnea, and enhances activities
of daily living
– Toxic side effects: tachyarrhythmias, nausea, vomiting,
seizures
– Monitoring should include intermittent serum level
measurements: target range 8-12mcg/mL
Inhaled Steroids (ICS) in Stable
COPD
• Glucocorticoids act at multiple points within the
inflammatory cascade.
• Regular treatment with ICS does not modify the
long-term decline in FEV1.
• Appropriate for symptomatic COPD patients with
an FEV1 < 50% and repeated exacerbations (Stage
III and IV).
• ICS reduce frequency of exacerbations and
improve health status (Evidence A).
• ICS combined with long-acting b2-agonist more
effective than individual components.
Steroids in Stable COPD
• GOLD guidelines recommend a trial of 6 weeks to
3 months of ICS to identify subset of patients who
may benefit.
• Short course of oral steroids is a poor predictor of
long-term response to ICS.
• Long-term treatment with oral steroids is NOT
recommended (Evidence A):
– No evidence of long-term benefit
– Major side effects: skin damage, cataracts, diabetes,
osteoporosis, secondary infection, psychosis, fluid
retention
Other pharmacologic treatments
• Vaccines: Influenza vaccine reduces serious illness and death in COPD
patients by 50%. Pneumococcal vaccine is recommended every 5 years
although data in COPD patients is lacking.
• Other anti-inflammatory agents: Cromolyn, nedocromil, and leukotriene
inhibitors have not been adequately tested in patients with COPD
• Alpha-1 Antitrypsin Augmentation Therapy: young patients with severe
deficiency and established emphysema
• Antibiotics are not recommended other than in treating infectious
exacerbations (Doxycycline, amoxicillin, macrolide, fluoroquinolones)
• Mucolytic agents: not recommended
• Antioxidants (N-acetylcysteine) may reduce the frequency of exacerbations
• Antitussives: contraindicated in stable COPD because cough is protective
• Comprehensive pulmonary rehabilitation programs
have been shown to improve all of the following
EXCEPT:
• A. Measured FEV1
• B. Respiratory symptoms
• C. 6-Minute walk test
• D. Need for outpatient care and inpatient
hospitalizations
• E. Symptoms of anxiety, depression, and lack of wellbeing
Pulmonary Rehabilitation in Stable COPD
• All COPD-patients benefit from exercise
training programs, improving with respect to
both exercise tolerance and symptoms of
dyspnea and fatigue (Evidence A).
• The minimum length of an effective rehab
program is 2 months; the longer the better
(Evidence B).
• Comprehensive pulmonary rehabilitation
program includes exercise training, nutrition
counseling, and education.
Manage Stable COPD: Oxygen
• The long-term administration of oxygen (> 15
hours per day) to patients with chronic respiratory
failure (Stage IV) has been shown to increase
survival (Evidence A).
• Oxygen administration reduces hematocrit,
pulmonary artery pressures, dyspnea, and rapid eye
movement related hypoxemia during sleep.
• Tailor prescription to patient: source, method of
delivery, duration of use, flow rate at rest, during
exercise, and sleep
Lancet 2003;362:1053-61
• A 59 year old male presents with worsening
shortness of breath. He was diagnosed with
COPD several years ago and was told to wear
oxygen at home. However, he doesn’t feel like
he needs it. He continues to exercise for several
minutes a day on the treadmill and does pullups. In the office, his O2 sats are 83% on room
air so he is admitted to the hospital. T 98.9 HR
103 R 24 BP 142/82 Sats 91% on 6 L oxymizer.
His weight is 144 lbs at 68 inches. He has
temporal wasting. He has supraclavicular
fullness, jugular venous distension to the jaw, a
prominent P2 on cardiac exam. He has poor air
movement throughout both lung fields.
• Pulmonary function tests: FEV1/FVC 28.6%
FEV1 0.51 L 18% predicted; FVC 1.8L 52%
predicted. With albuterol, his FVC increases to
2.07 L, a 14% improvement. His TLC is 151%
predicted. His RV is 359% predicted.
•
•
•
•
•
•
How would you rate his severity of disease?
How should this patient be treated?
What (if any) bronchodilators would you use?
Is there any role for inhaled corticosteroids?
What about systemic corticosteroids?
Any other beneficial interventions?
True or False
• COPD is a disease process limited to the lungs.
_______
• COPD is the only disease in which mortality
rates have been rising over the past several
decades. _________
COPD is a systemic disease
•
•
•
•
Systemic inflammation
Skeletal muscle dysfunction
Nutritional problems
High prevalence of depression and anxiety
– PRIME-MD: 1334 VA patients with COPD: 80%
screened positive for depression or anxiety
– Nicotine helps mitigate these symptoms
Percent Change in Age-Adjusted
Death Rates, U.S., 1965-1998
Proportion of 1965 Rate
3.0
3.0
2.5
2.5
Coronary
Heart
Disease
Stroke
Other CVD
COPD
All Other
Causes
–59%
–64%
–35%
+163%
–7%
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0 0
1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998
Trends in Age-Standardized Death Rates for the 6 Leading Causes of Death in the United States,
1970-2002
Jemal, A. et al. JAMA 2005;294:1255-1259.
Copyright restrictions may apply.
• COPD is the ___ leading cause of death in the
United States.
• A. 2nd
• B. 4th
• C. 6th
• D. 10th
Epidemiology
• 4th leading cause of death in the USA
• In 2000, WHO estimates 2.74 million deaths worldwide from
COPD
– In 2000, more women than men died of COPD in U.S. (59,936 vs 59,118)
• Age-adjusted death rates are rising
• High burden of disease
–
–
–
–
Approx. 16 million office visits (USA, 1995)
500,000 hospitalizations for COPD
Medical expenditures ~ 15 billion dollars/yr;
$32 billion in direct and indirect costs in 2002
Management Stage 0: At Risk for COPD
Characteristics
• Chronic symptoms
- cough
- sputum
• No spirometric
abnormalities
Recommended
Treatment
Avoidance of risk
factors:
Smoking cessation
Influenza vaccination
Management Stage I: Mild COPD
Characteristics
• FEV1/FVC < 70 %
• FEV1 > 80 %
predicted
• With or without
symptoms
Recommended
Treatment
• Add Short-acting
bronchodilator as
needed
Management of Stage II:
Moderate COPD
Characteristics
•FEV1/FVC < 70%
•50% < FEV1< 80%
predicted
•With or without
symptoms
Recommended
Treatment
•Add regular tx with
long-acting BD
•Pulmonary rehab
Management of Stage III: Severe COPD
Characteristics
•FEV1/FVC < 70%
•30% < FEV1 < 50%
predicted
•With or without symptoms
Recommended
Treatment
Add ICS if repeated
exacerbations
Management of Stage IV:
Very Severe COPD
Characteristics
•FEV1/FVC < 70%
•FEV1 < 30% predicted
or presence of
respiratory failure or
right heart failure
Recommended
Treatment
•Long-term oxygen therapy
•Treatment of complications
•Consider surgical options
Lancet 2003;362:1053-61
Surgical Treatments
• Bullectomy: In carefully selected patients, this
procedure is effective in reducing dyspnea and
improving lung function (Evidence C)
• Lung Volume Reduction Surgery
• Lung Transplantation: In appropriately selected
patients, improves quality of life and functional capacity
(Evidence C). Criteria for referral: FEV1<35%
predicted PaO2<55-60mm Hg, PaCO2>50 mm Hg, and
secondary pulmonary hypertension
Lung Volume Reduction Surgery
• National Emphysema Treatment Trial Research Group
• 1218 patients with severe emphysema underwent pulmonary
rehabilitation and were randomly assigned to undergo lungvolume reduction surgery or to receive continued medical
treatment
• Increases chance of improved exercise capacity but does not
confer a survival advantage
• Survival advantage for patients with predominantly upper-lobe
emphysema and low base-line exercise capacity
• A 70 year old male with GOLD stage III COPD
has had increased shortness of breath, chest
tightness, and a cough productive of yellow
sputum. In the ER, T 98.9 HR 115 R 32 BP
120/80 Sats 89% on 2 L O2 (his home O2
requirement). He is using accessory muscles
(sternocleidomastoids) and has
thoracoabdominal dyssynchrony. He has very
poor air movement bilaterally on lung exam.
The rest of his exam is unremarkable.
• How severe is his exacerbation?
• What lab tests/x-rays should you order?
• How should you treat him?
Symptoms
• Increased breathlessness, wheezing, chest tightness
• Increased cough and sputum
• Change in color and/or tenacity of sputum
– An increase in sputum volume and purulence points to a
bacterial cause
• Nonspecific complaints: fever, malaise, fatigue,
depression, confusion
Assessment of severity of
exacerbation
• Peak flow <100 L/min or FEV1 <1.0 L
indicates severe exacerbation
• ABG
• CXR
• EKG
• D-dimer, spiral CT
• Sputum culture
Manage Exacerbations: Key Points
• Inhaled bronchodilators
(Beta2-agonists and/or
anticholinergics),
theophylline, and systemic,
preferably oral, glucocorticosteroids are effective for the
treatment of COPD
exacerbations (Evidence A).
• 80% of AECB are
infectious. Environmental
factors and medication
nonadherence are 20%.
Manage Exacerbations: Key Points
• Noninvasive intermittent positive pressure
ventilation (NIPPV) in acute exacerbations
improves blood gases and pH, reduces inhospital mortality, decreases the need for invasive
mechanical ventilation and intubation, and
decreases the length of hospital stay (Evidence
A).
NIPPV
• Selection criteria:
– Moderate to severe dyspnea with use of accessory muscles and
paradoxical abdominal motion
– Moderate to severe acidosis and hypercapnia
– Respiratory frequency >25/min
• Exclusion criteria:
–
–
–
–
–
–
–
–
Respiratory arrest
Cardiovascular instability
Somnolence, impaired mental status, uncooperative patient
High aspiration risk
Viscous or copious secretions
Recent facial or gastroesophageal surgery
Craniofacial trauma
Extreme obesity
• He is admitted to 5500. How should he be
treated? The nurse calls you because the patient
is poorly responsive. T 98.6 HR 125 R 16 BP
110/65 Sats 92% on 50% face mask. Patient is
barely arousable by sternal rub. What do you
want to do now?
• Which of the following is NOT true about this
patient?
• A. His inpatient mortality rate is 25%.
• B. If he survives this hospitalization, he is likely
to be readmitted within 6 months.
• C. This is the ideal time to discuss code status
with the patient’s family.
• D. The patient’s five year mortality is 70%.
• Retrospective study of 57 patients with COPD
admitted to the ICU with a COPD exacerbation
• 90% intubated
• In-hospital mortality 24.5%
• Median survival 26 months
• Mortality rate at 5 years 69.6%
• Chest 2005; 128:518-24