Chronic Obstructive Pulmonary Disease (COPD) Jaime Palomino, MD Pulmonary/CCM Tulane University...
-
Upload
kelley-webster -
Category
Documents
-
view
212 -
download
0
Transcript of Chronic Obstructive Pulmonary Disease (COPD) Jaime Palomino, MD Pulmonary/CCM Tulane University...
Chronic Obstructive Pulmonary Disease (COPD)
Jaime Palomino, MDPulmonary/CCM Tulane University
10.22.09
INTRODUCTION
COPD is the most important lung disease in U.S.
25% of ED visits for Dyspnea 4th cause of death
Definition
Disease state characterized by airflow obstruction that is no longer fully reversible and is usually progressive
Accelerated declined in FEV1 from 30ml/year after 30y to 60ml
“Preventable and treatable”
AgeAge--Related Decline in FEVRelated Decline in FEV11 IsIsAccelerated in SmokersAccelerated in Smokers
FEV1, forced expiratory volume in 1 second.Adapted with permission from Fletcher C, Peto R. BMJ . 1977;1:1645-1648.
Never smoked or not susceptible to smoke
Stopped at 45 y
Stopped at 65 y
Smoked regularly and susceptible to its effects
0
25
50
75
100
FE
V1
(% o
f va
lue
at a
ge
25 y
)
25 50 75Age (y)
Disability
Death
Epidemiology COPD is the fourth leading cause of
death in the US.1
>25 million people in US have impaired lung fxn
Annual cost of COPD in the US ~ $30.4 billion (ALA)office visits, diagnostic procedures,
medications, and emergency and hospital services
1.Centers for Disease Control and Prevention. Mortality patterns—US, 1997. MMWR. 1999;48:664-678.
0
0.5
1.0
1.5
2.0
- 45% - 58% + 71% - 15%
CHD Stroke COPDP
rop
ort
ion
of
1966
mo
rtal
ity
rate All Other
Causes
1966-1986
Adapted with permission from Higgins MW, Thom T. In: Clinical Epidemiology of COPD. 1990:23-43.
Mortality of COPD Is IncreasingMortality of COPD Is Increasing
COPD is the only leading cause of death that is increasing.
COPD – Pathogenesis
Cosio et al. NEJM 2009;360:2445-54
Cosio et al. NEJM 2009;360:2445-54
Cosio et al. NEJM 2009;360:2445-54
COPD – Immunology
Cosio et al. NEJM 2009;360:2445-54
Cosio et al. NEJM 2009;360:2445-54
COPD – Pathogenesis
Sethi et al. NEJM 2008;359:2355-65
ACCP Pulmonary Board Review. 2007
COPD – Risk Factors
Diagnosis of COPD History
Smoking, occupational history Spirometry: FEV1, FEV1/FVC 6 minute walk to monitor fxnl status
distance a patient can walk on a flat path in 6 minutes
practical and reliable way to measure level of everyday impairment and exercise tolerance
Differential Diagnosis:Differential Diagnosis:Asthma Versus COPDAsthma Versus COPD11--33
Age of onset
Smoking history
Positive family history
History of atopy
Pattern of symptomoccurrence
Reversibility of airway obstruction
Triggers of exacerbations
Usually > 35-40 years
Usually 20 pack-years
Uncommon*
Unimportant
Nonspecific
Only partially reversiblewith smoking cessationand bronchodilator use
Infections, inhalant exposure
Any age (usually 40 years)
Minimal
Usually
Often positive
Nocturnal awakenings;early-morning symptoms
Usually near-normal pulmonary function with appropriate therapy
Specific identifiable triggers
COPD Asthma
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121. 3. Kuritzky L. Primary Care (Special Edition). 1999;3.
*Except for 1-antitrypsin deficiency
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
A Comparison of Four Sets of Staging Criteria for COPD
ACCP Pulmonary Board Review. 2007
COPD Severity (GOLD Guidelines)
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
Deterioration in Lung Function in Patients with COPD
ACCP Pulmonary Board Review. 2007
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
Pulmonary Hyperinflation in Patients with COPD
Celli, B. R. et al. N Engl J Med 2004;350:1005-1012
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 et al. CHEST 2008;133:1451-1462
Medications – Anticholinergics
Short-Acting: Ipratropium: Inhaled, nebs, (Atrovent-
HFA®) Long-Acting:
Tiotropium (Spiriva®)
Medications – Beta Agonists
Short-Acting: Albuterol (ProAir-HFA®, Proventil-HFA®, Ventolin-
HFA®) Pirbuterol (Maxair®) Metaproterenol (nebs) Levalbuterol (Xopenex® nebs, Xopenex-HFA®)
Long-Acting: Arformoterol (Brovana® nebs) Formoterol (Foradil®, Perforomist® nebs) Salmeterol (Serevent Diskus®)
Medications – ICS
Flunisolide (Aerobid®) Ciclesonide (Alvesco®) Mometasone (Asmanex Twisthaler®) Triamcinolone (Azmacort®) Fluticasone (Flovent Diskus®, Flovent
HFA®) Budesonide (Pulmicort Flexhaler®,
Pulmicort Respules® nebs) Beclomethasone (QVAR®)
Medications – Combinations
SABA + SAMA: Albuterol/Ipratropium (Combivent®, Duoneb®)
LABA + ICS: Fluticasone/Salmeterol (Advair Diskus®, Advair
HFA®) Budesonide/Formoterol (Symbicort®)
Medications – Others
Theophylline (Theo-24®, Uniphyl®)
Calverley et al. NEJM 2007;356:775-89
Calverley et al. NEJM 2007;356:775-89
Calverley et al. NEJM 2007;356:775-89
Celli et al. AJRCCM 2008;178:332-338
Calverley et al. NEJM 2007;356:775-89
Drummond et al. JAMA 2008;300:2407-2416
Sin et al. Lancet 2009;374:712-19
Tashkin et al. NEJM 2008;359:1543-54
Tashkin et al. NEJM 2008;359:1543-54
Tashkin et al. NEJM 2008;359:1543-54
Tashkin et al. NEJM 2008;359:1543-54
Lee et al. Arch Intern Med. 2009;169:1403-1410
Welte et al. AJRCCM.2009;180:741-750
Welte et al. AJRCCM.2009;180:741-750
Changes in Lung Function Number of Severe Exacerbations
Lee et al. Ann Intern Med 2008;149:380-390
Singh et al. JAMA 2008;300:1439-1450
Tashkin et al. NEJM 2008;359:1543-54
Medications
Theophylline or PDE Inhibitors May have a “come-back” Lower levels (8-13 mg/dL) Improvement in corticosteroid resistance
(HDAC2) Phosphodiesterase E4 inhibitors
Calverley et al. Lancet 2009;374:685-694
Smoking cessation Smoking cessation: single most effective
way to improve clinical outcomes in patients at all stages of COPD (asx-severe).1-4
After cessation, FEV1 rate of decline may decrease to the rate found in healthy nonsmokers.5,6
35% abstinent at 1 year, 22% at 5 years1. The National COPD Awareness Panel (NCAP). Guidelines for early detection and management of COPD. J Resp Dis. 2000;21(suppl):S5-S21.2. Centers for Disease Control and Prevention. The Surgeon General’s 1990 report on the health benefits of smoking cessation: executive summary – introduction, overview, conclusions. MMWR. 1990;39(RR-12):2-10.3. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled bronchodilator on the rate of decline in FEV1: the Lung Health Study. JAMA. 1994;272:1497-1505.4. Kanner RE. Early intervention in chronic obstructive pulmonary disease: a review of the Lung Health Study results. Med Clin North Am. 1996;80:523-547.5. Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ. 1977;1:1645-1648. 6. Higgins MW, Enright PL, Kronmal RA, et al. Smoking and lung function in elderly men and women. JAMA. 1993;269:2741-2748.
Smoking cessation
Ask: every patient, during each clinic visit
Advise: urge to quit Assess: willingness to quit Assist: quit plan, counseling,
social support, pharmacotherapy Arrange: follow-up contract
Vaccination
Pneumococcal vaccination Annual influenza vaccination
LongLong--Term Oxygen TherapyTerm Oxygen Therapy
Indicated for PaO2 <55 mm Hg or SaO2 <88%1
Improves1-4:
– Survival in hypoxemic patients
– Cognitive function, affect
– Exercise performance
– Sleep quality
– Activities of daily living
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. Report of the Medical Research Council Working Party. Lancet. 1981;681-686.3. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93:391-398. 4. Bye et al. Am Rev Respir Dis. 1985;132:236-240.
Pulmonary Rehabilitation
Casaburi et al. NEJM 2009;360:1329-35
Pulmonary Rehabilitation Improves (better than other COPD therapies):
Exercise capacity Severity of dyspnea Health-related quality of life
Reductions in hospitalization Improvements in cost-effectiveness Reduction in depression and anxiety Improves cognitive function and self-efficacy Survival benefit has not been demonstrated Reimbursement varies
Casaburi et al. NEJM 2009;360:1329-35
Pulmonary Rehabilitation Indications:
GOLD Stage 3 or 4 3 times/week. 3-4 hrs/session. 6 – 12 weeks Endurance exercise leg muscles
Walking, stationary cycling, treadmill Resistance-exercise component Upper extremities exercise Bronchodilators, oxygen, NIPPV, heliox,
anabolic steroids Education, smoking cessation, nutrition
Casaburi et al. NEJM 2009;360:1329-35
Treatment - COPD Lung Transplant
< 65 y/o High BODE index Effects on survival remains controversial
LVRS (pneumoplasty) Upper lobe disease Limited exercise performance after pulmonary
rehabilitation FEV1 : 20 -35 % predicted Bronchoscopic placement of one-way valves
or biological substances
Tillie-Leblond et al. Ann Intern Med. 2006;144:390-396
Rizkallah et al. CHEST 2009;135:786-793
Zvezdin et al. CHEST 2009;136:376-380
Treatment - NPPV
NPPV fewer intubations, decreased mortality, and shortened MICU admissions
Indications for NPPV pH < 7.20 RR > 25 MS change worsening hypercapnia