1、COPD,All you wanted to know about COPD but were afraid to ask,What to expect:,Definition Epidemiology Risk Factors History/Physical Findings Diagnostic Studies Overview of Current Treatment Options Treatment of exacerbations,What is COPD?,a disease state characterized by airflow limitation that is n
2、ot fully reversible. Includes: Emphysema: an anatomically defined condition characterized by destruction and enlargement of the lung alveoli. Chronic Bronchitis: a clinically defined condition with chronic cough and phlegm; and small airways disease, a condition in which small bronchioles are narrow
3、ed.,Epidemiology:,Currently 4th leading cause of Death in United States (also on the rise in Europe, Africa and Asia) With recent increase in female smoking, COPD now affects men and women equally, with early COPD patients now being predominately women. Non-caucasian ethnic groups are also catching
4、up to caucasians in prevalence of COPD. Very Costly: Direct cost of COPD in 2002 were $18 billion.,Risk Factors,SMOKING Airway hyper-responsiveness Occupational/Environmental Exposures mining, textiles, ?second hand smoke Genetics alpha-1-antitrypsin deficiency There has been familial COPD clusters
5、so other genetic factors likely play a role as well,Think about COPD if your patient has:,Cough Sputum Production Often first thing in the morning. Exertional Dyspnea Activities involving significant arm work, particularly at or above shoulder level, are particularly difficult for patients with COPD
6、. Conversely, activities that allow the patient to brace the arms and use accessory muscles of respiration are better tolerated. Any of those risk factors from the last slide,What do you see on exam?,Most often nothing obvious, especially early in disease state-could be normal Often more helpful to
7、rule out other diseases with similar symptoms (e.g heart failure) Classic Pink Puffer/Blue Bloater Not very often.,Diagnosis,COPD requires Spirometry for diagnosis and staging. FEV1 FVC FEV1/FVC ratio: indicator of airway flow limitation FEV1/FVC 70% predicted=limited airflow Cannot be fully reverse
8、d by bronchodilators,GOLD CRITERIA FOR COPD SEVERITY,I:Mild COPD . FEV1/FVC 70% FEV1 = 80% predicted with or without chronic symptoms (cough, sputum production) II:Moderate COPD . FEV1/FVC 70%, FEV1 50-80% predicted with or without chronic symptoms (cough, sputum production) III: Severe COPD . FEV1/
9、FVC 70% FEV1 30-50% predicted with or without chronic symptoms (cough, sputum production) IV: Very Severe COPD . FEV1/FVC 70% FEV1 30% predicted or FEV1 50% predicted plus chronic respiratory failure *Notice how FEV1/FVC must be 70%,Differential Diagnosis,Similar Symptoms: Asthma Heart Failure Pneum
10、onia Even chronic sinusitis,Similar PFT profile Asthma Cystic Fibrosis Bronchiectasis Some bronchiolitis,Treatment: What has SHOWN benefit?,Smoking Cessation Oxygen Therapy mortality rate inversely proportional to #hours/day O2 is worn. Certain criteria, not everyone benefits immediately Lung Reduct
11、ion Surgery in emphysema National Emphysema Treatment Trial Mostly for upper lobe emphysema,Pharmacological Symptomatic Relief,Bronchodilators-symptomatic Anticholinergics (Anti-ACh)-symptomatic AND acute FEV1 improvement Tiotropium-reduces exacerbations Beta Agonists-short vs. long-acting LABA as g
12、ood as Anti-AChs-added together = improvement in symptoms and PFT profile Inhaled Corticosteroids-ongoing trials Can help prevent further exacerbations,Non-pharmacological therapies:,Flu Shot EVERY year PneumoVax Pulmonary Rehabilitation Lung Transplantation,Acute exacerbation,change in the patients
13、 baseline dyspnea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management,ATS Guidelines for Hospitalization:,The presence of high-risk comorbid conditions pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure Inade
14、quate response of symptoms to outpatient management Marked increase in dyspnea,Inability to eat or sleep due to symptoms Worsening hypoxemia Worsening hypercapniaChanges in mental statusInability of the patient to care for her/himself (lack of home support)Uncertain diagnosis.,Treatment,Bronchodilat
15、ors Supplemental Oxygen Either nasal cannula or Noninvasive Positive Pressure Ventilation if needed. Steroids (Yes- N Engl J Med 1999;340:1941-7) If tolerated orals, Prednisone 30-40mg daily x 10d Cant do that? Equivalent IV dose.,Note on steroids:,JAMA. 2010;303(23):2359-2367 Not ideal study: Cohor
16、t, composite end point Comparing Non-ICU level patients receiving IV vs. Oral steroids for acute COPD exacerbation. IV dose: 120-800mg/day prednisone equivalent (yikes) Oral dose: 20-80mg/day prednisone End point: Treatment failure need for mechanical ventilation after hospital day#2 readmission wit
17、h in 30 days inpatient mortality No worse outcome with low dose oral steroids compared to high dose IV form.,Treatment,Antibiotics? If change in sputum (purulent, color change) in hospitalized patients Usually given if patient is admitted to ICU Respiratory Fluoroquinolones Amoxicillin/Clavulanate I
18、nitial Trial (Ann Intern Med 1987;106:196-204)-showed modest benefit but did not control for use of steroids. Newer Trial (Am J Respir Crit Care Med. 2010 Jan 15;181(2):150-7) compared 7 day course of doxycycline to placebo with all getting steroids, showed earlier clinical improvement (better at da
19、y 10) but no improvement in lung function or at day 30.,A few notes on Asthma,Defined as: Airway Inflammation Airway hyperresponsiveness Reversible-key difference from COPD Well defined “Step up/down” therapy algorithm for primary therapy. SMART trial showed increase in death related to LABA alone,
20、so dont do it. This study has its own pro/cons-not in scope of this talk though.,ncbi.nlm.nih.gov,Exacerbations,Check peak flow-compare to baseline values Albuterol MDI/nebs-as often as needed Steroids-usually oral, no recent trials like for COPD NO data showing antibiotics are of benefit unless the
21、 exacerbation is caused by pneumonia or other infection which would normally be treated with antibiotics.,References:,ATS website: www.thoracic.org GOLD website:www.GOLDCOPD.com ACP medicine-COPD chapter. Lindenauer, P.K , et.al Association of Corticosteroid Dose and Route of Administration With Ris
22、k of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease. JAMA. 2010;303(23):2359-2367 Anthonisen NR, Manfreda J, Warren CPW et al. Antibiotic therapy in exacerbations of COPD. Ann Intern Med 1987;106:196-204. Daniels, J.M.A, et.al Antibiotics in Addition to Systemic Corticosteroids for Acute Exacerbations of Chronic Obstructive Pulmonary Disease Am J Respir Crit Care Med. 2010 Jan 15;181(2):150-7,
