1、CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL PRACTICE GUIDELINES REVIEW WEEK 1: DIAGNOSIS,AMBULATORY INTERNAL MEDICINE GROUP PRACTICEUNIVERSITY HEALTH NETWORK / MSHSEPTEMBER 2007Prepared by: Dr. D. Panisko,COPD: Guidelines for this Seminar,Standards for the diagnosis and treatment of patients with
2、 COPD: a summary of the ATS/ERS position paper. Celli BR et al. Eur Respir J 2004; 23: 932-46. Full document, with updates, available at: www.thoracic.org, accessed Sept 2007Canadian Thoracic Society recommendations for the management of chronic obstructive pulmonary disease - 2003. ODonnell DE et a
3、l. Can Respir J 2003; 10(SupplA): 11A-33AGlobal Initiative for Chronic Obstructive Lung Disease. (GOLD). A collaborative of the NIH and WHO. Updated Nov 2006, accessed Sept 2007. Available at ,COPD Diagnosis: Objectives,After this seminar you should: be aware of diagnostic clinical practice guidelin
4、es for stable chronic COPD be able to define COPD and asthma and outline a differential diagnosis be able list important historical and laboratory diagnostic features of COPD be able to describe the evidence-based physical examination for COPD and airflow limitation,COPD I: DIAGNOSIS,CASE: A 61 year
5、 old man comes to your clinic as a new patient. He had just been admitted to hospital for his first exacerbation of COPD. He has completed a 10 day antibiotic course and 10 days of oral Prednisone. He is now only on an ipratropium puffer, 2 puffs qid.How is COPD defined ? What is emphysema ? What is
6、 asthma ? Why is it important to make a diagnosis of COPD (as opposed to asthma) in this patient ?,COPD I: DIAGNOSIS,COPD Definition: A preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associat
7、ed with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.Implies post bronchodilator FEV1/FVC0.7ATS/ERS position paper,COPD I: DIAGNOSIS,COPD: tradi
8、tionally understood as a spectrum - components of chronic bronchitis or emphysema. The latter may take on revitalized significance because of a new approach that considers the importance of different phenotypes of COPD.EMPHYSEMA: Abnormal permanent enlargement of the airspaces distal to the terminal
9、 bronchioles, accompanied by destruction (lack of uniformity in the pattern of airspace enlargement; the orderly appearance of the acinus and its components is disturbed and may be lost) of their walls and without obvious fibrosis.,Emphysema = Pink Puffer !,Gross Pathological Changes of Emphysema,Mi
10、croscopic Changes of Emphysema,COPD I: DIAGNOSIS,ASTHMA: A chronic inflammatory disorder of the tracheobronchial tree, many cells and cellular elements play a role, leading to airway hyperreactivity and reversible airflow limitation. IMPLICATION: airway can return to normal between attacks or with t
11、reatment BUT in chronic asthma a condition similar to COPD can develop with irreversibility and progression of the airflow limitation.It is also important to make a diagnosis of asthma as there are differences in therapy for asthma and COPD.,COPD I: DIAGNOSIS,CASE (cont.):Can the severity of COPD be
12、 staged ? What is the relevance and importance of staging a patient with COPD ?,GOLD: Classification of COPD Severity by Spirometry,Stage I: Mild FEV1/FVC 80% predicted Stage II: Moderate FEV1/FVC 0.7050% FEV1 80% predictedStage III: Severe FEV1/FVC 0.7030% FEV1 50% predictedStage IV: Very Severe FE
13、V1/FVC 0.70FEV1 30% predicted or FEV1 50% predicted plus chronic respiratory failure,COPD I: DIAGNOSIS,What is the relevance and importance of staging a patient with COPD ?Stages (GOLD) are currently mainly for educational and research purposes Not extensively validated by trials Represent expert co
14、nsensus opinion Some treatment recommendations exist based on patient stage presumably will be further validated by clinical trials Canadian guidelines list another severity scale but do not recommend treatment on that basis,COPD I: DIAGNOSIS,CASE (cont.):What historical features contribute to the d
15、iagnosis of COPD ? What are other important features of the hx ?,COPD I: DIAGNOSIS,Important historical information:age of onset of symptoms quantify exposure to risk factors i.e.: tobacco smoke occupational exposures exposure to outdoor and indoor air pollution presence of liver disease family hist
16、ory childhood respiratory illnesses information that allows a diagnosis of chronic bronchitis,COPD I: DIAGNOSIS,Perform respiratory functional inquiry to determine current symptom status and to classify COPD: asymptomatic intermittent symptoms (on exertion, nocturnal/sleep) regularly symptomatic sev
17、erely symptomatic frequency and course of exacerbations,COPD I: DIAGNOSIS,CASE (cont.):What is the differential diagnosis of COPD ?,COPD I: DIAGNOSIS,Differential Diagnosis of COPD:Cystic fibrosis, asthma, bronchiectasis, and bronchiolitis obliterans (all specific causes of airflow limitation) have
18、been conventionally excluded from the diagnosis definition of COPD and therefore are part of the dx dx.Interstitial lung disease (fibrosis, TB, hypersensitivity pneumonitis, sarcoidosis, pneumoconioses, etc.) may also present in a patient with recurrent shortness of breath, exacerbations, and cough.
19、 Consider a variety of non-pulmonary causes of breathlessness (i.e. CHF),COPD I: DIAGNOSIS,CASE (cont.): This patient indicates a three year history of productive cough, at least on 50% of days, and an audible wheeze with SOBOE. His symptoms have been progressing over the entire year and he now gets
20、 SOB with 1 flight of stairs or 3 level blocks. He has a 45 pack year smoking history, has worked in an office all of his life, and has no relevant past medical, childhood, or family history.What are indications for screening for alpha-1 antitrypsin deficiency ? Should this patient be screened? How
21、can screening be performed ?,COPD I: DIAGNOSIS,Screen for alpha-1 antitrypsin deficiency if patient is under the age of 45, has a predominance of basilar emphysema, has a minimal smoking history, has a family history of early onset COPD, has a known family history of alpha-1 antitrypsin deficiency,
22、or associated liver disease.Screening therefore not indicated in the case. Screening: serum assay for alpha-1 antitrypsin level 10cc of clotted blood in red top tube (on a misc. req. at UHN). For update on genetics of COPD see Rabe et al. 2007,COPD I: DIAGNOSIS,CASE:What physical exam maneuvers are
23、helpful to diagnose airflow limitation ?,Not this one !,COPD I: DIAGNOSIS,Evidence Based Physical Exam: See: 1) Holleman, Rational Clinical Examination Series. Does the clinical examination predict airflow limitation ? JAMA 1995; 273: 313-9 2) Straus SE. McAlister FA. Sackett DL. Deeks JJ. The accur
24、acy of patient history, wheezing, 17: 684-8,COPD I: DIAGNOSIS,Wheezing: Grade: A Positive likelihood ratio: 36 Barrel Chest: B, 10 Decreased Cardiac Dullness: B, 10 Match Test: B, 7.1 Hyperresonance: B, 4.8 Forced Expiratory Time 9 seconds: A, 4.8 Subxiphoid Apical Impulse: B, 4.6 Pulsus Paradoxus 1
25、5mmHg: C, 3.7 Decreased Breath Sounds: B, 3.7 Forced Expiratory Time 6 - 9 seconds: A, 2.7* Many other signs not systematically evaluated (diaphragmatic levels, pursed lip breathing, use of accessory muscles, indrawing),COPD I: DIAGNOSIS,Straus et als important contributions to the literature have s
26、hown that a single physical sign is not as useful as a combination of historical and physical findings to make a diagnosis of COPDThey have published two modelsWhat maneuvre is being performed ?,COPD I: DIAGNOSIS,Combined history/physical exam Model I:Smoking 40 P.Y. (LR 8.3) Self reported history o
27、f COPD (LR 7.3) Maximum laryngeal height (LR 2.8) Age 45 years (LR 1.3)Combined all 4: +LR 220 Combined patients with none: -LR 0.13,COPD I: DIAGNOSIS,Combined history/physical exam Model II:*Forced Exp Time 9 sec (LR 6.7) Multivariate: (LR 4.6) *Self reported history of COPD (LR 5.6) (LR 4.4) *Whee
28、zing (LR 4.0) (LR 2.9) Smoked longer than 40 pack years (LR 3.3) Male gender (LR 1.6) Age over 65 years (LR 1.6)*Combined all 3: +LR 59.0 *Combined patients with none: -LR 0.3,COPD I: DIAGNOSIS,CASE (cont.):Physical examination of our patient was only relevant for a barrel chest, diffuse occasional
29、audible wheezes, and a forced expiratory time of 7 seconds. Laryngeal height was 5 cm.There were no signs of cor pulmonale. Otherwise, the exam was unremarkable.,COPD I: DIAGNOSIS,CASE (cont.):Which of the following investigations are currently indicated ? How will they help in the care of this pati
30、ent ? in the care of other patients with stable COPD ?Spirometry Full Pulmonary Function Tests CXR Helical CT of chest Allergy testing O2 saturation (rest, exercise, sleep) ABG,COPD I: DIAGNOSIS,Spirometry: Performed for diagnosis, prognosis, monitoring of therapy. FEV1, FVC, and ratio most importan
31、t; peak flows not recommended. Pulmonary Function Tests: Full PFTs not necessary for routine dx, usually performed at the time of initial dx to establish baseline, may be useful for dxdx - i.e to obtain bronchodilator reversibility testing to asses for asthma.CXR: Useful in exacerbations and for its
32、 r/o value for other dxdx. Has low sens. and spec. for the dx of emphysema, thus not recommended by guidelines.,COPD I: DIAGNOSIS,Helical CT of Chest: Not necessary for routine diagnosis, may be useful for dxdx or for lung volume reduction OR.Allergy Testing: May have use in asthma, not COPD.O2 Sat:
33、 In severe COPD (stage 2b or 3) useful to guide O2 therapy. Nocturnal desaturations are probably under diagnosed.ABG: Needed to guide long term oxygen therapy and to obtain government funding for same. (See guidelines for actual criteria for initiation of treatment will be discussed next week).,COPD
34、 I: DIAGNOSIS,CASE (cont.):The current Canadian guidelines: do not emphasize evidence based diagnosis for patients with COPD put more emphasis on evaluation of impairment, disability with exercise testing, dyspnea assessment scales, and quality of life assessment scales do not give specific recommen
35、dations on how or at what point in the patients course these evaluations should be used,COPD: other useful references:,2 recent review series on COPD: 5 article series on exacerbations:Thorax Feb June, 2006 12 article series:BMJ May 13th to July 22nd, 2006Excellent recent update: Update in Chronic Obstructive Pulmonary Disease 2006: Rabe KF, et al. Am J Resp Crit Care 2007; 175: 1222-1232,COPD I: DIAGNOSIS,Next week:COPD II - Therapy,
