COPD

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COPD

• All you wanted to know about COPD but were afraid
  to ask

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What to expect

• Definition
• Epidemiology
• Risk Factors
• History/Physical Findings
• Diagnostic Studies
• Overview of Current Treatment Options
• Treatment of exacerbations

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What is COPD?

• a disease state characterized by airflow
  limitation that is not 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
  narrowed.

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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 up
  to caucasians in prevalence of COPD.
• Very Costly Direct cost of COPD in 2002 were
  18 billion. 

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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 so other
  genetic factors likely play a role as well

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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.
  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

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What do you see on exam?

• Most often nothing obvious, especially early in
  disease state-could be normal
• Often more helpful to rule out other diseases
  with similar symptoms (e.g heart failure)
• Classic Pink Puffer/Blue Bloater
• Not very often.

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Diagnosis

• COPD requires Spirometry for diagnosis and
  staging.
• FEV1
• FVC
• FEV1/FVC ratio indicator of airway flow
  limitation
• FEV1/FVC lt 70 predictedlimited airflow
• Cannot be fully reversed by bronchodilators

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GOLD CRITERIA FOR COPD SEVERITY

• IMild COPD . FEV1/FVC lt 70 FEV1 80
  predicted with or without chronic symptoms
  (cough, sputum production)IIModerate COPD .
  FEV1/FVC lt 70, FEV1 50-80 predicted with or
  without chronic symptoms (cough, sputum
  production)III Severe COPD . FEV1/FVC lt 70
  FEV1 30-50 predicted with or without chronic
  symptoms (cough, sputum production)IV Very
  Severe COPD . FEV1/FVC lt 70 FEV1 lt 30
  predicted or FEV1 lt 50 predicted plus chronic
  respiratory failure
• Notice how FEV1/FVC must be lt70

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Differential Diagnosis

• Similar Symptoms
• Asthma
• Heart Failure
• Pneumonia
• Even chronic sinusitis

• Similar PFT profile
• Asthma
• Cystic Fibrosis
• Bronchiectasis
• Some bronchiolitis

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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 Reduction Surgery in emphysema
• National Emphysema Treatment Trial
• Mostly for upper lobe emphysema

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Pharmacological Symptomatic Relief

• Bronchodilators-symptomatic
• Anticholinergics (Anti-ACh)-symptomatic AND acute
  FEV1 improvement
• Tiotropium-reduces exacerbations
• Beta Agonists-short vs. long-acting
• LABA as good as Anti-AChs-added together
  improvement in symptoms and PFT profile
• Inhaled Corticosteroids-ongoing trials
• Can help prevent further exacerbations

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Non-pharmacological therapies

• Flu Shot EVERY year
• PneumoVax
• Pulmonary Rehabilitation
• Lung Transplantation

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Acute exacerbation

• change in the patients baseline dyspnea, cough
  and/or sputum beyond day-to-day variability
• sufficient to warrant a change in management

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ATS Guidelines for Hospitalization

• The presence of high-risk comorbid conditions
• pneumonia, cardiac arrhythmia, congestive heart
• failure, diabetes mellitus, renal or liver
  failure
• Inadequate response of symptoms to outpatient
  management
• Marked increase in dyspnea

• Inability to eat or sleep due to symptoms
• Worsening hypoxemia
• Worsening hypercapnia
• Changes in mental status
• Inability of the patient to care for her/himself
  (lack of home support)
• Uncertain diagnosis.

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Treatment

• Bronchodilators
• Supplemental Oxygen
• Either nasal cannula or Noninvasive Positive
  Pressure Ventilation if needed.
• Steroids (Yes- N Engl J Med 19993401941-7)
• If tolerated orals, Prednisone 30-40mg daily x
  10d
• Cant do that? Equivalent IV dose.

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Note on steroids

• JAMA. 2010303(23)2359-2367
• Not ideal study Cohort, 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
  day2
• readmission with in 30 days
• inpatient mortality
• No worse outcome with low dose oral steroids
  compared to high dose IV form.

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Treatment

• Antibiotics?
• If change in sputum (purulent, color change) in
  hospitalized patients
• Usually given if patient is admitted to ICU
• Respiratory Fluoroquinolones
• Amoxicillin/Clavulanate
• Initial Trial (Ann Intern Med 1987106196-204)-sh
  owed modest benefit but did not control for use
  of steroids.
• Newer Trial (Am J Respir Crit Care Med. 2010 Jan
  15181(2)150-7) compared 7 day course of
  doxycycline to placebo with all getting steroids,
  showed earlier clinical improvement (better at
  day 10) but no improvement in lung function or at
  day 30.

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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, so dont do it.
• This study has its own pro/cons-not in scope of
  this talk though.

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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 exacerbation is caused by pneumonia or other
  infection which would normally be treated with
  antibiotics.

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References

• ATS website www.thoracic.org
• GOLD websitewww.GOLDCOPD.com
• ACP medicine-COPD chapter.
• Lindenauer, P.K , et.al Association of
  Corticosteroid Dose and Route of Administration
  With Risk of Treatment Failure in Acute
  Exacerbation of Chronic Obstructive Pulmonary
  Disease. JAMA. 2010303(23)2359-2367
• Anthonisen NR, Manfreda J, Warren CPW et al.
  Antibiotic therapy in exacerbations of COPD. Ann
  Intern Med 1987106196-204.
• 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 15181(2)150-7