Download Management of Chronic Airflow Obstruction

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
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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
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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
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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
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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