Management of Asthma and COPD

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Management of Asthma and COPD

• W.S. Krell M.D.
• Wayne State University

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NIH Statement (1992, 97)

• Chronic inflammatory disorder
• multiple cellular components, mediators
• recurrent wheeze, shortness of breath, chest
  tightness, cough (pm early am)
• reversible airflow obstruction
• secondary hyperresponsiveness
• Sub-basement membrane fibrosis

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Treating Asthma

• Medications
• long term or controller medications
• quick relief medications
• Stepped therapy start high, back down
• Asthma monitoring and action plans
• Environmental controls

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Overview of Medications

• Controller medications
• control inflammation
• long duration bronchodilation
• multiple medications
• Quick relief medications
• for intermittent or breakthrough symptoms

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Controller Agents

• Inhaled corticosteroids
• Systemic corticosteroids
• Long acting ?2 agonists
• Cromolyn and derivatives
• Methylxanthines
• Leukotriene Modifiers

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Inhaled Corticosteroids

• Control airway inflammation locally
• Ideal control asthma (high local potency) no
  side effects (low systemic effects)
• fluticasone, budesonide
• beclomethasone
• (triamcinolone, flunisolide)

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Systemic Corticosteroids

• May be needed initially
• Side effect profile well known
• Step down therapy
• Alternatives high dose inhaled corticosteroids
  methotrexate other immunosuppressive drugs
  Omalizumab

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Omalizumab (Xolair)

• Recomb. DNA derived IgG - selectively binds human
  IgE
• Indication mod. to severe persistent asthma not
  controlled w/inhaled CS
• IgE gt 30, RAST A or skin tests
• Given SQ/ mo. or biweekly
• Dose based on wt. and IgE level

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Long acting ß2 Agonists

• Salmeterol
• Formoterol
• Prolonged duration
• Potentiate steroid effects?
• Should we be using them????????

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Leukotriene Modifiers

• Anti-inflammatory
• Precursor step affected
• Compliance may be better than MDIs
• Few side effects

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Other Controllers

• Cromolyn derivatives
• Safe, effective
• Less predictable, frequent dosing
• Methylxanthines
• Mechanism not fully understood
• Therapeutic/Toxic ratio high
• Multiple drug interactions

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Quick Relief Medications

• ß2 Agonists
• Systemic corticosteroids

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Exacerbation of Asthma

• History Sudden (exposure) vs gradual worsening
  vs viral infection vs non-compliance
• Tachypnea, tachycardia
• Accessory muscles
• Wheezing, prolonged expiration, silent
• Speaking ability compromised

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ABGs - Asthma

• Respiratory alkalosis
• Normal PCO2 is worrisome
• Rising PCO2 is near respiratory failure
• Note O2 doesnt fall until late so pulse
  oximetry is not very sensitive

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Emergency Management

• Nebulized albuterol x 3
• Monitor exam, peak flows, ABGs
• If no improvement, start IV corticosteroids and
  admit
• DOSE?? (30 to 180 mg/day)
• Asthma CXR not likely helpful

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Further Mgt of Asthma

• Continue bronchodilators
• Q 6 hour steroids
• Hydration
• Mucomyst may exacerbate
• If failing consider anticholinergics,
  theophylline, single isomer ß2, Mg2

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Impending Respiratory Failure

• Respiratory acidosis
• Decreasing mental status
• Asthma PCO2 above 40 or rising despite therapy

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Outpatient Asthma Management

• Classify by severity
• Step up and down number of medications based on
  symptoms and peak flows

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Severity of Asthma

• Mild Intermittant
• symptoms lt 2X/wk
• nightslt2/month
• Mild persistent
• gt 2X/wk but lt 1/day
• Nights gt 2/month

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(cont.)

• Moderate
• Daily symptoms
• Nights gt 1/week
• SEVERE
• Continual symptoms
• Frequent nighttime symptoms

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Rules of 2

• Sx gt 2/week
• PM sx gt 2 nights/month
• gt 2 rescue MDIs/year

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Stepped Therapy

• Inhaled beta agonist
• Inhaled corticosteroid
• Long acting beta agonist
• Leukotriene modifiers
• (Cromolyn derivatives)
• (Theophyllines)
• Systemic corticosteroids

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Patient Education

• Avoid triggers
• Home monitoring
• Proper inhaler techniques
• Spacers
• Asthma Action Plan

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Compliance?

• Few patients continue to document
• Always give them Action Plans
• Simple in office questionnaire
• validated in testing
• Snap shot of asthma control

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Asthma vs. COPD

• Sensitizing agent
• ?
• Inflammation
• CD4 T-lymphocytes
• Eosinophils
• ?
• Completely reversible
• airflow limitation

• Noxious agent
• ?
• Inflammation
• CD8 T-lymphocytes
• Macrophages, PMNs
• ?
• Irreversible airflow limitation

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Treating COPD

• Step up
• Long acting Anticholinergics
• Long acting beta agonists
• Short acting bronchodilators
• (steroids inhaled and oral)
• Soon Cilomalist?

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Exacerbation of COPD

• Viral or secondary bacterial infection
• Non-compliance
• Cor pulmonale
• Tachypnea, tachycardia
• Rhonchi, wheezes, prolonged expiration
• Signs of right heart failure, pulmonary
  hypertension

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Causes

• Infections (bacterial)
• Environmental (? pollution)
• Unknown in 1/3

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Management

• Increase bronchodilators
• Systemic steroids (PO if possible) (A)
• Shortens recovery time
• Quicker return to baseline function
• ? risk of early exacerbation
• 10 day to 2 week course
• Antibiotics (B)

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Additional Management COPD

• Nebulized anticholinergics, ß agonists
• Antibiotics
• Steroids
• Manage other complications pneumonia,
  pneumothorax, right heart failure
• Oxygen to keep saturation near 90

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ABGs - COPD

• Pay more attention to pH, bicarb
• PCO2 elevations more significant when acute
• Expect increased (A-a)DO2
• Hypoxia must be treated, despite fears of
  hypercarbia

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Impending Respiratory Failure

• Non Invasive Ventilation
• Bi-level Positive Pressure
• Increase inspiratory P to ? pCO2
• Start expiratory P at 5-6 cm H2O and ? if needed
  for oxygenation
• Evidence A for success

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Management of COPD

• Smoking cessation
• Spirometry
• Yearly influenza vaccine
• Pneumovax
• Antibiotics for exacerbations
• Monitor rest and exercise oxygenation

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Spirometry is KEY

• FEV1
• FEV1/FVC Ratio
• Screen based on exposure and symptoms
• Follow at least yearly
• Patients should KNOW THEIR NUMBERS

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Spirograms
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Classification
STAGE FEV1/FVC FEV1
0 gt70 gt 80 Symptoms
I lt 70 80 Symptoms
II lt 70 50 but lt 80 Sx
III lt 70 30 but lt 50 Sx
IV lt 70 lt 30 or lt 50 chronic respiratory failure
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Management All Stages

• Avoidance of noxious exposures
• SMOKING CESSATION (Evidence A)
• Avoid occupational/environmental exposures
  (Evidence B)
• Vaccination
• Influenza
• Pneumovax

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Smoking Cessation Strategies

• Repeated counseling
• Nicotine replacement agents
• Buproprion, anxiolytics
• This is the ONLY measure available proven to halt
  the decline in lung function
• Evidence A

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COPD Outpatient

• SHORT ACTING BETA AGONISTS
• ANTICHOLINERGICS
• Ipatropium
• Tiotropium
• LONG ACTING BETA AGONISTS
• Theophyllines
• Inhaled corticosteroids

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Management Stage I

• Short acting bronchodilator used PRN
• Albuterol beta 2 agonist
• Ipatropium M3 anticholinergic blocker
• Both are effective
• Albuterol has faster onset of action
• Combination is additive for bronchodilation
• Evidence A

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Management Stage II

• Long acting bronchodilators
• Long acting beta agonists
• Long acting anticholinergic
• Short acting bronchodilators PRN
• Education
• Inhaled corticosteroids if frequent exacerbations
• Evidence A

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Long Acting Beta Agonists

• Formoterol
• Onset comparable to short acting agents
• Duration 12 hours
• Salmeterol
• Slower onset
• Duration 12 hours
• Cautions re use without inhaled steroids
  applies to asthmatics not COPD patients

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Tiotropium

• Duration 24 hours
• Blocks M1 and M3 receptors
• Stop ipatropium (M3 only)
• Few side effects (some caution with BPH)
• Sustained improvement in FEV1

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What about Theophylline?

• Old drug, proven useful
• If chosen, careful monitoring required
• High toxic to therapeutic ratio
• Multiple drug and food interactions
• Aim for levels 8 12 mcg/mL

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Cilomalist

• Orally active PDE4 inhibitor ? cAMP (inflam,
  bronchial reactivity)
• Positives
• Improved FEV1, reduced sx (SGRQ)
• Negatives
• Significant GI toxicity
• Study done prior to release of tiotropium
• Rennard, CHEST 2006

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Inhaled Corticosteroids

• If indicated, choose long acting agents
• Fluticasone
• Combination drug with salmeterol
• Budesonide
• Also available for use in nebulizer

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More is better???

• Combinations can produce benefits
• Long acting agents are ALL expensive
• Optimal combinations not known

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Management Stage III

• One or More Long acting Bronchodilators
• Short acting bronchodilators PRN
• Inhaled corticosteroids if frequent exacerbations
• Pulmonary Rehabilitation
• Evidence A

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Management Stage IV

• Long acting bronchodilators
• Short acting bronchodilators PRN
• Inhaled corticosteroids
• Education
• Evaluate need for oxygen therapy
• Nighttime non-invasive ventilation?
• Consider surgical options

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Surgical Options

• Lung transplantation
• Upper age limit 60 years
• Consider for younger patients without serious
  co-morbidities
• Few last long enough to get transplanted
• Lung volume reduction surgery
• Consider if no serious co-morbidities
• Improves diaphragmatic function

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Resources

• NIH Asthma Guidelines
• www.nhlbi.gov/guidelines/asthma/
• Global Initiative for chronic obstructive lung
  disease
• www.goldcopd.com
• Resource for asthma action plans, info
• www.cine-med.com/asthma/