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Management of Chronic Airflow Obstruction J.R. Sheller, M.D. Allergy, Pulmonary & Critical Care Medicine Chronic Airflow Obstruction • Asthma • COPD – emphysema/chronic obstructive bronchitis • Bronchiectasis – cystic fibrosis • Obliterative bronchiolitis • 12.1 million adults ages 25 and older reported being diagnosed with COPD; 21 million asthmatics • Total estimated cost of COPD $32.1 billion, asthma was $13.8 • COPD is the fourth leading cause of death in the U.S. and is projected to be the third leading cause of death by the year 2020. • 5000 deaths/yr from asthma Spirometry Functional residual capacity 100 FEV1 (%) max 50 Disability Death 20 Time (yrs) 40 80 100 FEV1 (%) 50 Disability Death 20 Time (yrs) 40 80 Smoking Cessation • Counseling – Has patient thought about stopping? – Rehearse reasons to quit – Offer to help • Group therapy – quitting sessions Cancer Society, Heart Assoc., Lung Assoc. • Medications – Wellbutrin – Nicotine – Clonidine Bronchodilators • Beta2 adrenergic agonists – By metered dose inhaler – By nebulizer • Short acting – albuterol, terbutaline – rescue medicine • Long acting – salmeterol, formoterol – Not used for “rescue” Anticholinergics • Ipratropium • Tiatropium Work best in COPD Viral exacerbations of asthma in children Theophylline • Methylxanthines – adenosine antagonists, phosphodiesterase inhibitors, induces histone deactylase • Narrow therapeutic window • Not important in emergency • May help in difficult cases • Phosphodiesterase 4 inhibitor Antiinflammatory RX • • • • Can improve function Can improve symptoms Uncertain if it alters natural history May affect structural changes (remodeling) Inhaled Corticosteroids • Topically active • Delivered to the airway • First pass liver metabolism reduces systemic availability • Unknown mechanism of action Inhaled Corticosteroids • Theoretical: – suppression of adrenals – growth retardation in kids • Known: – oral thrush and vocal cord dysfunction – Increased cataracts – Increased loss of bone • Beclomethasone – 2 puffs QID • Triamcinalone – 2 inhalations TID • Fluticasone – 2 inhalations BID (3 strengths) • Flunisolide – 2 inhalations BID • Budesonide – 2 inhalations BID Convenient, cheap Leukotriene Modifiers • Zileuton – 5 Lipoxygenase inhibitor • Receptor antagonist – Zafirlukast 20mg BID – Montelukast 10mg QD COPD • • • • 72 year old smoker for 60yrs Cough, sputum production, dyspnea FEV1 33% predicted; DLCO 25% predicted Rhonchi, wheezes, pedal edema DX: Chronic obstructive bronchitis and emphysema http://www.goldcopd.com/ COPD Rx • • • • • Smoking cessation Inhaled ipratropium, beta agonist using MDI Long acting beta adrenergic - salmeterol Flu vaccine, pneumovax Antimicrobials for increased sputum (amoxicillin, doxycycline, macrolides, trimethoprim/sulfa) • Inhaled corticosteroids controversial • Avoid oral steroids • Calls with low grade fever, dyspnea, ankle edema • Admitted to hospital with SaO2 75% • Oxygen by nasal prongs • BiPAP (non invasive ventilation) • Systemic steroids – iv methylprednisolone, convert to oral (60mg prednisone) • Nebulized ipratropium/albuterol • Pneumovax, influenza vaccine Home Oxygen • SaO2 <89% (or pulmonary hypertension, Hct >55, CHF) • Should be used 24hrs day • After 6 weeks, recheck sats (50% of patients no longer need it) Home oxygen tethers patients, causing deconditioning Pulmonary rehab, activity are important • 35 year old female with episodic cough, wheezing, dyspnea after jogging • Childhood history of asthma • Atopic (hay fever) • Normal exam • FEV1 normal; FEV1/FVC reduced • Albuterol MDI prior to exercise • Medication works, but she uses it each day • Add inhaled steroids • Now awakening at night with cough • Add long acting beta agonist (salmeterol, formoterol; or combination, eg Advair, Symbicort) • Rehearse inhaler use, action plan • Allergy/Pulmonary consultation http://www.nhlbi.nih.gov/about/naepp/ • Still having problems with dyspnea, uses albuterol several times a day • GERD, Sinus disease • Increase inhaled steroids • Add leukotriene modifier Montelukast, zafirlukast – receptor blockers Zileuton – inhibitor of 5-lipoxygenase • Consider theophylline • Anti IgE (omalizumab) • Has symptoms of URI, using albuterol every 2hrs, not getting relief • ED Rx – Oxygen – Continuous albuterol – Intravenous methylprednisolone 125mg – Ipratropium – Mg may help those with most severe obstruction – Measure PEFR, FEV1, pulsus paradoxus – Admit in 2hrs if no improvement Risk of death in Asthma • • • • • Frequent hospitalizations Intubated for asthma Poor perception of airflow obstruction Frequent albuterol rescue medication use Psychosocial problems Treatment Scheme • Mild intermittent • Mild persistent • Moderate • Severe b-agonists + inhaled steroids salmeterol, more inhaled steroids, leukotriene modifiers theophylline, oral steroids, anti IgE