Transcript Non-Pharmacologic Therapy

COPD
Ambulatory Rotation - Block 4
Ryan Burris
Brian Dang
Minh-Phuong (Michelle) Le
Jennifer Mah
Ben Yip
COPD Definition
• The Global Initiative for Chronic Obstructive Lung
Disease (GOLD) and World of Health Organization
(WHO) Definition:
"Chronic obstructive pulmonary disease (COPD), a
common preventable and treatable disease, is
characterized by airflow limitation that is usually
progressive and associated with an enhanced chronic
inflammatory response in the airways and the lung to
noxious particles or gases. Exacerbations and
comorbidities contribute to the overall severity in
individual patients.”
COPD Diagnosis
• Symptoms of COPD
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Dyspnea on exertion or rest
Cough
Cachexia, cyanosis
Wheezing
Limitation of activities
• Smoking history
– Obtain a pack year history; the higher the PY, the greater the
risk of developing COPD.
• Environmental history
• Occupational history
COPD Diagnosis
• Pulmonary function tests
– FEV1/FVC < 70%
– FEV1 < 80%
• CXR
– Hyperinflation
– Flattened diaphragms
– Long narrow heart
– Interstitial markings and bullae
COPD Diagnosis
COPD Diagnosis
• Other clues but not necessary for diagnosis
– ABG with hypercapnia and hypoxemia
– Decreased DLCO
– Negative BNP
– Spirometry shows
• Dec IC and VC
• Increased TLC, FRC, and RV due to hyperinflation
COPD Diagnosis
• Rule out other DDX of symptoms and obstructive
disease
– Can rule out asthma with
• Bronchodilator challenge: Positive if improvement of FEV1 ≥
12% after albuterol
• Methacholine challenge: Positive if decrease in FEV1 ≤ 20%
with methacholine
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Alpha 1 anti-trypsin deficiency
Congestive heart failure
Bronchiectasis
Bronchitis
Tuberculosis
COPD Severity
TREATMENT OPTIONS?
Non-Pharmacologic Therapy
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Smoking cessation
Reduce environmental exposures
Physical activity
Vaccinations
– Influenza, pneumococcal
• Supplemental O2
• Pulmonary rehabilitation
• CPAP
Pharmacologic Therapy
Bronchodilators
• Beta2 agonists
• Anticholinergics
• Theophylline
(methylxanthine)
Inhaled Corticosteroids
• For FEV1 < 60%
• Don’t use as monotherapy!
Many different combinations…
Class
Generic
Brand
SA beta2-agonists
Albuterol
ProAir, Proventil
LA beta2-agonists
Formoterol
Salmeterol
SA anticholinergics
Ipratropium bromide
Atrovent
LA anticholinergics
Tiotropium
Spiriva
Combo SA beta agonist +
anticholinergic
Albuterol/Ipratropium
Combivent
ICS
Beclomethasone
Budesonide
Fluticasone
Combo LA beta agonist +
corticosteroid
Formoterol/Budesonide
Salmeterol/Fluticasone
Symbicort
Advair
Practically speaking,
what do I use?
Patient
Group
First Choice
Generic
Brand Names
A
SA anticholinergic prn
Ipratropium
Atrovent
or SA beta agonist prn
or Albuterol
or ProAir
LA anticholinergic
Tiotropium
Spiriva
or LA beta agonist
or Formeterol or
Salmeterol
or Formeterol or
Salmeterol
ICS + LA beta agonist
Formoterol/Budesonide
Salmeterol/Fluticasone
Symbicort or
Advair
or Tiotropium
or Spiriva
Formoterol/Budesonide
Salmeterol/Fluticasone
and/or
Tiotropium
Symbicort or
Advair
and/or
Spiriva
B
C
or LA anticholinergic
D
ICS + LA beta agonist
and/or
LA anticholinergic
Patient Group
First Choice
Alternative
Other Options
A
SA anticholinergic prn
LA bronchodilator
Theophylline
or SA beta agonist prn
or SA beta agonist + SA
anticholinergic
LA anticholinergic
LA anticholinergic and
LA beta agonist
B
or LA beta agonist
SA beta agonist
and/or SA
anticholinergic
Theophylline
C
ICS + LA beta agonist
or LA anticholinergic
LA anticholinergic and
LA beta agonist
or LA anticholinergic +
PDE-4 inhibitor
SA beta agonist
and/or SA
anticholinergic
Theophylline
or LA beta agonist and
PDE-4 inhibitor
D
ICS + LA beta agonist
and/or
LA anticholinergic
ICS + LA beta agonist and LA
anticholinergic
or ICS + LA beta agonist and PDE-4
inhibitor
or LA anticholinergic and LA beta
agonist
or LA anticholinergic and PDE-4
inhibitor
Carbocysteine
SA beta agonist
and/or SA
anticholinergic
Theophylline
ACUTE EXACERBATIONS
Exacerbation - Definition
• An acute event characterized by a worsening of
the patient’s respiratory symptoms that is beyond
normal day-to-day variations and leads to a
change in medication
– Changes in dyspnea, cough, and/or sputum
production
• Precipitants: most common causes are viral upper
respiratory tract infections and infection of
tracheobronchial tree; air pollutants
• Clinical diagnosis based on presentation of the
patient
Its significance?
• Negatively affect a patient’s quality of life
• Have effects on symptoms and lung function that
take weeks to recover
• Accelerate the rate of decline of lung function
• Associated with significant mortality, particularly
in those requiring hospitalization
• High socioeconomic costs
Where to treat patient?
Treatments
• Ipratropium + albuterol (metered dose inhaler or
nebulizer): 1st line
• Corticosteroids: increase FEV1 but no mortality benefit
(prednisolone x10-14d or methylprednisolone x72h)
• +/- Antibiotics x5-10d: increase in dyspnea, sputum
volume, sputum purulence
– amox, bactrim, doxy, clarithro, cipro/levo
– Haemophilus influenzae, Streptococcus pneumoniae, Moraxella
catarrhalis
– GOLD 3 & 4: Pseudomonas aeruginosa
• Intravenous methylxanthines (theophylline or
aminophylline): only in selected cases when response to
short-acting bronchodilators is insufficient
Oxygenation
• Supplemental O2: goal SaO2 88-92%, PaO2 55-60
– Helps to prevent intubation, decrease in mortality
– Not for AMS, cannot clear secretions, HD instability, UGIB
• Intubation: acidosis, PaO2 <55-60, high PaCO2, worsening
dyspnea, not NPPV candidate
Treatment Goals
• Minimize the impact of the current exacerbation
• Prevent the development of subsequent
exacerbations
• Abx and steroid: shorten recovery time, improve
lung function (FEV1) & arterial hypoxemia (PaO2),
reduce the risk of early relapse, treatment failure,
and length of hospital stay
MKSAP QUESTIONS!
MKSAP Question 1
• A 48 year old man is evaluated for a 1-year history of cough. He has
not had dyspnea, abdominal pain, heartburn, or change in appetite
or weight. He has a 30 pack year history of smoking. He does not
have seasonal allergies. His medical history is significant for
hypertension that is treated with losartan.
• On physical examination, vital signs are normal. Pulmonary
examination discloses normal breath sounds that are equal
bilaterally with no wheezing. No nasal polyps are noted. Abdominal
examination is unremarkable. There is no cyanosis, clubbing, or
edema. Pulmonary function tests disclose an FEV1 of 75% of
predicted and an FEV1/FVC ratio of 63%. Following administration
of a bronchodilator, there is no significant change in the FEV1/FVC
ratio, and the FEV1 is 83% of predicted. Chest radiography shows no
masses and normal lung markings.
MKSAP Question 1
• Which of the following is the most likely cause
of this patient’s cough?
– A) Asthma
– B) COPD
– C) Gastroesophageal reflux disease
– D) Losartan
MKSAP Question 1
• Which of the following is the most likely cause
of this patient’s cough?
– A) Asthma
– B) COPD
– C) Gastroesophageal reflux disease
– D) Losartan
MKSAP Answer 1
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The most likely cause of this patient’s cough is COPD. His post bronchodilator
FEV1/FVC ratio less than 70% confirms airflow limitation and a diagnosis of
obstructive lung disease’ his relatively preserved FEV1 suggests that his COPD is
mild. COPD should be considered in any patient older than 40 years who has
dyspnea, chronic cough or sputum production, and/or a history of risk factors
(such as exposure to tobacco smoke, dust, chemicals, outdoor air pollution, or
biomass smoke). Spirometry is the gold standard for diagnosing COPD and
monitoring its progress; it should be done to confirm the diagnosis and to exclude
other diseases. The American College of Physicians and Global Initiative for
Chronic Obstructive Lung Disease (GOLD) Guidelines require an FEV1/FVC ratio of
less than 70% of predicted to establish the diagnosis of COPD. The GOLD
guidelines use the degree of airflow obstruction as measured by the FEV1 to
further describe the level of disease. Level 1 (mild) COPD is characterized by an
FEV1 of 80% of predicted or greater; Level 2 (moderate) COPD is characterized by
an FEV1 of 50% to 79% of predicted; Level 3 (Severe) COPD is characterized by an
FEV1 of 30% to 49% of predicted; and Level 4 (Very severe) COPD is characterized
by an FEV1 less than 30% of predicted.
MKSAP Answer 1
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Although asthma may present with cough, it is unlikely in this patient owing to
the lack of atopy and history of respiratory symptoms as a child or any other
clinical findings consistent with bronchospasm
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Gastroesophageal reflux disease may cause cough; however, COPD is the more
likely cause of cough in this patient who does not have heartburn symptoms,
has a history of smoking, and demonstrates airflow obstruction on pulmonary
function testing.
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ACE inhibitors may be associated with cough, but angiotensin receptor
blockers (such as losartan) have a significantly lower rate of cough as a side
effect and would not be a likely cause of this patient’s cough given his other
clinical parameters.
MKSAP Question 2
• A 66 year old man is evaluated in the intensive care unit for possible
extubation. He was admitted for a severe COPD exacerbation 3 days ago.
His carbon dioxide remained markedly elevated despite a trial of
noninvasive ventilation, and he was therefore intubated and placed on
invasive mechanical ventilation. He has improved with treatment of his
COPD. His medications are methylprednisolone, albuterol, ipratropium,
propofol, and levofloxacin.
• On physical examination, he is awake and responsive. Temperature is 37.0
°C (98.6 °F), blood pressure is 138/82 mm Hg, pulse rate is 96/min, and
respiration rate is 20/min. Pulmonary examination reveals decreased
breath sounds bilaterally with no wheezing. Accessory muscle use is
noted. A small amount of thin secretions is noted with endotracheal
suctioning.
• Arterial blood gas levels have returned to baseline, with a pH of 7.36, a
PCO2 of 55 mm Hg (7.3 kPa), and a PO2 of 70 mm Hg (9.3 kPa) on an
FIO2 of 0.35. He tolerates a weaning trial well and the decision is made to
extubate.
MKSAP Question 2
• Which of the following interventions will
decrease this patient's risk for reintubation?
– A) Incentive spirometry every 2 hours
– B) Inhaled helium-oxygen mixture
– C) Nebulized N-acetylcysteine
– D) Noninvasive positive pressure ventilation
MKSAP Question 2
• Which of the following interventions will
decrease this patient's risk for reintubation?
– A) Incentive spirometry every 2 hours
– B) Inhaled helium-oxygen mixture
– C) Nebulized N-acetylcysteine
– D) Noninvasive positive pressure ventilation
MKSAP Answer 2
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The most appropriate intervention at the time of extubation is noninvasive
positive pressure ventilation (NPPV). Application of NPPV shortly after extubation
for a 24-hour period reduced the need for reintubation in previous trials of
intubated patients with chronic lung disease and hypercapnia after a successful
weaning trial. This population also appears to benefit from NPPV even if it is not
applied until after the patient has developed respiratory failure following
extubation. However, studies enrolling unselected patients with postextubation
respiratory failure indicate that the use of NPPV may actually increase mortality.
The use of incentive spirometry reduces the risk of postoperative pulmonary
complications but does not have a role in the routine management of nonsurgical
patients following extubation.
The reduced gas density of helium-oxygen mixtures (heliox) reduces resistance to
airflow, and thereby the work of breathing, in patients with obstructive lung
disease. However, there is insufficient evidence to support the routine use of
heliox in the management of COPD exacerbations.
N-acetylcysteine is a mucolytic agent that has been used to thin secretions in
patients with excess mucus production. However, N-acetylcysteine is less likely to
benefit this patient because he had minimal secretions prior to extubation.
Furthermore, nebulized N-acetylcysteine may trigger bronchospasm.
MKSAP Question 3
• A 70-year-old woman is evaluated during a routine examination.
She has severe COPD with recurrent exacerbations and decreasing
exercise capacity. She does not have cough or fever, but she has
dyspnea with activities of daily living. She stopped smoking 1 year
ago and is adherent to her medication regimen. Her inhaler
technique is good. Her medications are fluticasone/salmeterol,
tiotropium, and an albuterol inhaler as needed.
• On physical examination, pulse rate is 80/min and respiration rate is
22/min; BMI is 22. Pulmonary examination reveals diminished
breath sounds that are equal bilaterally. No wheezing or crackles
are noted. FEV1 is 45% of predicted. Oxygen saturation is 92% at
rest and 90% after exertion breathing ambient air. Chest radiograph
shows no infiltrate or mass.
MKSAP Question 3
• Which of the following is the most appropriate
management?
– A) Morphine
– B) Oxygen therapy
– C) Prednisone
– D) Pulmonary rehabilitation
MKSAP Question 3
• Which of the following is the most appropriate
management?
– A) Morphine
– B) Oxygen therapy
– C) Prednisone
– D) Pulmonary rehabilitation
MKSAP Answer 3
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Pulmonary rehabilitation is the most appropriate management for this patient. Current
guidelines recommend pulmonary rehabilitation for symptomatic patients with an FEV1 less than
50% of predicted. Pulmonary rehabilitation may be considered for symptomatic or exerciselimited patients with an FEV1 greater than or equal to 50% of predicted, but this is a weaker
recommendation based upon moderate-quality evidence. Exercise training improves skeletal
muscle function and reduces dynamic hyperinflation. Benefits of pulmonary rehabilitation
include improvement in exercise capacity, reduction in the perceived intensity of breathlessness,
improvement in health-related quality of life, and reduction in anxiety and depression associated
with COPD. It is not recommended for patients who cannot walk or who have unstable angina or
recent myocardial infarction.
Morphine can be used in palliation for patients with severe dyspnea, especially at rest. However,
this patient's dyspnea is not severe, so morphine is not appropriate at this time.
This patient's oxygenation is adequate, and supplemental oxygen is not required. Oxygen
therapy is indicated for patients who have hypoxemia, arterial PO2 of 55 mm Hg (7.3 kPa) or
lower, or oxygen saturation of 88% or lower.
This patient has no indication for a short-term course of a systemic corticosteroid because she
does not have evidence of an acute exacerbation. An exacerbation of COPD is defined as an
acute event characterized by a change in baseline dyspnea, cough, and/or sputum production
beyond normal daily variation. The main symptoms include increased dyspnea often
accompanied by wheezing and chest tightness, increased cough and sputum production, change
in the color and/or tenacity of sputum, and fever. Various nonspecific signs and symptoms such
as fatigue, insomnia, depression, and confusion may accompany these findings.
MKSAP Question 4
• A 56-year-old man is evaluated in follow-up for COPD,
which was diagnosed last week with spirometry; his
FEV1 is 58% of predicted. He has a morning cough
productive of sputum and dyspnea with moderate
exertion. He quit smoking at the time of diagnosis. His
only medication is a nicotine patch. He is started on a
short-acting bronchodilator and is given appropriate
vaccinations.
• On physical examination, vital signs are normal. The
lungs are clear to auscultation, but prolonged
expiration is noted. The remainder of the physical
examination is normal.
MKSAP Question 4
• Which of the following is the most appropriate
management?
– A) Budesonide inhaler
– B) Oral montelukast
– C) Oral prednisone
– D) Tiotropium inhaler
MKSAP Question 4
• Which of the following is the most appropriate
management?
– A) Budesonide inhaler
– B) Oral montelukast
– C) Oral prednisone
– D) Tiotropium inhaler
MKSAP Answer 4
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The most appropriate management is to begin a long-acting bronchodilator such as tiotropium. The
2011 American College of Physicians, American Thoracic Society, and European Respiratory Society
guideline on the diagnosis and management of stable COPD recommends that for stable patients
with symptomatic COPD and an FEV1 of less than 60% of predicted, the treatment is an inhaled
bronchodilator (strong recommendation, moderate-quality evidence). Further, the guideline
recommends that clinicians prescribe monotherapy using either long-acting inhaled anticholinergics
or long-acting inhaled β2-agonists for symptomatic patients with COPD and FEV1 less than 60% of
predicted (strong recommendation, moderate-quality evidence). There is no evidence that one is
superior to the other. Clinicians should base the choice of specific monotherapy on physician or
patient preference, cost, and adverse effect profile. For patients with stable COPD with respiratory
symptoms and FEV1between 60% and 80% of predicted, the guideline suggests that treatment with
inhaled bronchodilators may be used (weak recommendation, low-quality evidence).
The guideline suggests that clinicians may administer combination inhaled therapies (long-acting
inhaled anticholinergics, long-acting inhaled β2-agonists, or inhaled corticosteroids) for symptomatic
patients with stable COPD and FEV1 of less than 60% of predicted (weak recommendation,
moderate-quality evidence). An inhaled corticosteroid such as budesonide as monotherapy is not
recommended owing to its lack of clinical benefit compared with an inhaled bronchodilator.
Leukotriene modifiers such as montelukast have not been adequately tested in patients with COPD
and are not recommended.
A short course of systemic corticosteroids is used in patients with an acute COPD exacerbation, but
long-term use of systemic corticosteroids is not recommended owing to adverse effects.
MKSAP Question 5
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A 62-year-old man is evaluated during a routine examination. He has very
severe COPD and has had multiple recent exacerbations and several
hospitalizations over the past 2 years. During his last two hospitalizations he
had acute hypercapnia requiring intubation. He has completed pulmonary
rehabilitation twice, most recently 3 months ago, and his exercise capacity
remains poor. He is adherent to his medication regimen. He used to smoke
two packs per day but now only smokes two or three cigarettes per day. He is
on 2 L of oxygen. His current medications are a fluticasone inhaler, salmeterol,
tiotropium, roflumilast, and albuterol as needed.
On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is
130/85 mm Hg, pulse rate is 88/min and regular, and respiration rate is
22/min. Pulmonary examination discloses distant breath sounds without
wheezing.
Oxygen saturation is 92% on 2 L of oxygen. Pulmonary function testing
discloses an FEV1 of 18% of predicted, an FEV1/FVC ratio of 38%, and a DLCO of
15% of predicted. Chest radiograph shows a flattened diaphragm and
decreased lung markings.
MKSAP Question 5
• Which of the following is the most appropriate
next step in management?
– A) Increase oxygen
– B) Lung transplantation evaluation
– C) Lung volume reduction surgery evaluation
– D) Repeat pulmonary rehabilitation
– E) Smoking cessation
MKSAP Question 5
• Which of the following is the most appropriate
next step in management?
– A) Increase oxygen
– B) Lung transplantation evaluation
– C) Lung volume reduction surgery evaluation
– D) Repeat pulmonary rehabilitation
– E) Smoking cessation
MKSAP Answer 5
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The most appropriate next step in management is to advise this patient to quit smoking. He meets criteria for
possible lung transplantation based on the severity of his COPD. However, substance addiction (alcohol,
tobacco, or narcotics) that is current or active within the last 6 months is an absolute contraindication to lung
transplantation. This patient is still smoking and therefore should be advised to quit. Transplantation in patients
with COPD should be considered if deterioration continues despite appropriate, maximal medical therapy in
patients without clear contraindications to the procedure. The BODE (BMI, Obstruction, Dyspnea, Exercise)
index is a method for assessing severity of COPD and is based on health care quality-of-life measures and
independent predictors of disease-related mortality. A BODE score of greater than 5 is an indication for referral
for evaluation for lung transplantation. Transplantation is indicated in patients with a BODE index of 7 to 10 and
at least one of the following: history of hospitalization for exacerbation associated with hypercapnia;
pulmonary hypertension, cor pulmonale, or both despite oxygen therapy; FEV1 of less than 20% of predicted
and either DLCO of less than 20% of predicted or homogeneous distribution of emphysema. Referral for lung
transplantation would be appropriate for this patient only if he stops smoking.
This patient's oxygenation is adequate; therefore, increasing the oxygen is not appropriate, especially in a
patient with a history of acute hypercapnia. Oxygen therapy is indicated for patients who have hypoxemia,
arterial PO2 less than 55 mm Hg (7.3 kPa), or arterial oxygen saturation of 88% or lower.
Patients with an FEV1 of less than 20% of predicted and either a DLCO of less than 20% of predicted or
homogeneously distributed emphysema are considered high risk for lung volume reduction surgery (LVRS).
Because this patient's FEV1 and DLCO are less than 20% of predicted, this patient is not an ideal candidate for
LVRS.
Pulmonary rehabilitation is very effective in patients with advanced COPD, and repeated courses or continuous
pulmonary rehabilitation has value. However, it is not a definitive treatment for patients with severe disease
who would otherwise be eligible for lung transplantation.
References
• Global strategy for the diagnosis, management, and
prevention of chronic obstructive pulmonary disease:
Revised 2015. Global Initiative for Chronic Obstructive
Lung Disease (GOLD). www.goldcopd.org (Accessed on
September 21, 2015).
• Qaseem A, Snow V, Shekelle P, et al. Diagnosis and
management of stable chronic obstructive pulmonary
disease: a clinical practice guideline from the American
College of Physicians. Ann Intern Med 2007; 147:633
• UpToDate