Transcript Cyclospora - Morning Report

COPD/ASTHMA
Fernando Catalan
Kelly Carew
Tom Moran
COPD
Definition
Differential
Diagnosis
Classical
presentation
Diagnosing
COPD
Treatment
WHO on COPD
Today
 12th commonest cause of morbidity
 4th commonest cause of death worldwide
By 2020
 5th most common cause of morbidity
 3rd most common cause of death
What is COPD
Differential Diagnosis
COPD
Asthma
Acute
Bronchitis
CHF
Lung
Cancer
Pneumonia
COPD Classic findings
AP diameter of chest

diaphragmatic excursion
 Wheezing
 Prolonged expiratory phase
Less classic findings:





Max laryngeal height of < 4cm on inspiration
Dyspnea on exertion
Cigarette smoking
Most pts at least 40 yrs old
Studies

Pulmonary Function Testing (PFT)
FEV1 – Air expelled in 1 second
 FVC – Forced Vital Capacity – total amount of
air that can be taken into the lung
 Results- based on PREDICTED values of a
healthy standardized population
 If FEV1/FVC ratio is less than 70% of the
predicted  pt has COPD

Spirometry
Staging of COPD, GOLD criteria





FEV1/FVC < 70% for all stages of COPD
Mild: FEV1 predicted ≥ 80%; pt unaware of
lung function decline
Moderate: FEV1 btw 50 & 80%, SOB on
exertion
Severe: FEV1 btw 30 & 50%, SOB becomes
worse and COPD exacerbations are common
Very Severe: FEV1 < 30%, quality of life is
gravely impaired. COPD exacerbations can
be life threatening
Chest Radiograph
Management

Bronchodilators Short/Long acting:
albuterol/salmeterol

Anticholinergics : Ipratropium, tiotropium
 Inhaled

glucocorticoids
Systemic glucocorticoids
Smoking cessation: Ask Advice Asses Assist Arrange
 Update immunizations: Influenza &
Pneumococcal polysaccharide
 Educate about COPD exacerbations

Smoking cessation
COPD Exacerbations

Cardinal signs of COPD Exacerbations

Dyspnea
Sputum volume
Sputum purulence
Inhaled bronchodilators
 Oral glucocorticosteroids
 Antibiotics
 Non-invasive mechanical ventilation
 Medication and education on prevention

Summary
COPD: >40yrs old, smoker, dypnea,
laryngeal height < 4cm on expiration
 PFT: FEV1/FVC < 70%, FEV1: 80/50/30
 Treatment:

All pts with symptoms:Short or Long acting
bronchodilator
 Combination medications work better than
high doses of one medication


A
B
C
D
E
F
Mr. Smith is a 58 yo male who presented with dyspnea on exhertion,
productive cough of whitish sputum, with a 40 pack-year of smoking,
physical exam reveals increased AP diameter, laryngeal height 2 cm
above the sternal notch, and expiratory wheezing -- Which of the
following is the best next step in diagnosis? Select the ONE best
answer.
Serum creatinine
Pulmonary angiogram
Stress echocardiogram
Pulmonary function testing
Chest CT
Chest radiography

The correct answer is D.
Pulmonary function testing (PFT) is the gold standard for diagnosing COPD. It is also the best screening
tool for COPD, as it is sensitive enough to detect COPD in its early stages, long before disabling effects
are apparent. It should, therefore, be used to confirm the presence of the disease in any patient thought
to be at risk of COPD. In pulmonary function testing, either a FEV1/FVC ratio less than the 5th
percentile, or less than 70% predicted, confirms a diagnosis of COPD. On the next card, we will have a
more in-depth explanation of PFTs.
Serum creatinine is helpful for diagnosing renal insufficiency.
A pulmonary angiogram, although a risky and expensive procedure, serves as the gold standard for
diagnosing pulmonary embolism, not COPD.
A stress echocardiogram can confirm cardiac ischemia.

A chest CT could diagnose cancer. Chest CT often serves as a reasonable gold standard for diagnosing
pulmonary embolism, because pulmonary angiography is so risky.
Chest radiographs are seldom diagnostic in COPD. Radiographic findings are usually more suggestive
of advanced COPD, including: hyperinflation (flattened diaphragm on lateral chest film and increased
volume of retrosternal air space), hyperlucency of the lungs, and rapid tapering of the vascular markings.
Asthma
Asthma

Inflammatory hyperreactivity of the respiratory tree to
various stimuli

Reversible airway obstruction

Mucosal inflammation, bronchial muscular constriction,
excessive secretion of viscous mucous causing
mucous plugs

Occurs in episodic pattern with interspersed normal
airway tone

Seen at any age, usually in young persons
Asthma: Etiology
Intrinsic (idiosyncratic) asthma

Occurs in 50% of asthmatics who are nonatopic

Triggers: nonimmunologic stimuli, such as
infections, irritating inhalants, cold air, exercise,
emotional upset

Attacks are severe, prognosis is less favorable
Etiology
Extrinsic (allergic, atopic) asthma

Sensitization: precipitated by allergens

IgE produced

Accounts for 20% of asthmatics

Other symptoms: allergic rhinitis, urticaria,
eczema

Prognosis is good
Etiology
Aspirin Sensitivity-Nasal Polyposis Syndrome

Affects adults; prevalence is ~10%

Usually starts with perennial vasomotor rhinitis; later,
minimal ingestion of aspirin elicits asthma

Cross-reactivity between aspirin and NSAIDS

Desensitization by daily administration of aspirin

Mechanism: chronic overexcretion of leukotrienes,
which activate mast cells
Pathophysiology

Narrowing of airways caused by




Histamine, bradykinin, leukotrienes,
prostaglandins


Hypertrophy and spasm of bronchial smooth
muscle
Edema and inflammation of the bronchial mucosa
Production of viscous mucous
Bronchoconstriction and vascular congestion
Mast cells, lymphocytes, and eosinophils
Asthma Severity Classification

Mild Intermittent asthma: symptoms twice a week or less,
bothered by symptoms at night twice a month or less.

Mild persistent asthma: symptoms more than twice a
week, but no more than once in a single day, bothered by
symptoms at night more than twice a month.

Moderate persistent asthma: symptoms every day,
bothered by nighttime symptoms more than once a week.

Severe persistent asthma: symptoms throughout the day
on most days, bothered by nighttime symptoms often.
DIAGNOSIS
Clinical
History
Physical exam
HEENT – general allergy symptoms
Lungs – Expiratory wheezes,
Decreased I/E ratio.
Skin – atopic dermatitis
DIAGNOSIS

Pulmonary Function Testing
FEV1-This is the volume of air expired in the
first second during maximal expiratory effort
FVC-total volume of air expired after a full
inspiration.
CBC: eosinophilia
 CXR: Hyperinflation

Spirometry
Peak Flow Meter
Assessing an Asthma Attack
1)
2)
Distress?
Distinguishing the severity by PEF or
FEV1
a.
b.
3)
>50% of predicted is mild to moderate
<50% of predicted is severe
ABG
a.
b.
Initially low pCO2
Eventually elevated pCO2
TREATMENT
Relief meds
Acute relief from symptoms
Preventers
anti-inflammatory
Controllers
Have sustained bronchodilation effects,
but anti-inflammatory action is unproven
Treatment - Relievers
1) Short-acting Beta2 agonists
(albuterol)
2) Anticholinergics
(Ipratropium bromide)
TREATMENT - Preventers
1)Inhaled corticosteroids
2) Cromones
(Cromolyn and nedocromil)
TREATMENT - Controllers
1) Long acting Beta2 agonists
(Salmeterol andFormoterol)
2) Methylxanthines
(Theophylline)
3) Leukotrieneantagonists
(Zafirlukast and Montelukast)
(Zileuton)
Treatment
Classification
Severity of Sx.
NightimeSx
FEV
Treatment
Mild
Intermittent
Sx<2x/wk,
otherwise
asymptomatic
Sx<= 2x/mo
>80%
Beta 2 agonist
Mild Persistent Sx> 2x/wk,
<1x/day
Sx>=2x/mo
>80%variability
from 20-30%
1)Low-dose ICS
2)Cromolyn
3) Leukotriene
Antagonist
Moderate
Persistent
DailySx, Daily
use of beta2
agonist
Sx>=1x/wk
60% - 80%
1) Medium
dose ICS
2) Long acting
B2 agonist
Severe
Persistent
Continual Sx.
Frequent
<60%
1) High dose
ICS
2) Long acting
B2 agonist
PATIENT EDUCATION
Asthma Action Plan
1) obtain a personal best PEF
2) Chart Green, yellow, red
Green – 80-100% of personal best PEF
Yellow – 50-80%
Red - <50%
Question
A 24yo AAF presents at your primary care office with a slightly
elevated temperature, and headache. She has a PMH significant
for severe asthma. Physical shows a decreased
inspiratory/expiratory ratio as well as nasal polyps. What
recommendations concerning antipyretic and analgesic use are
important to convey before the pt leaves the office?

A) Administer only acetaminophen for fever and discomfort.
B) Administer ibuprophen q6 for 48 hrs.
C) Administer Motrin for q6 for 48 hrs.

D) Administer only NSAIDs for fever and discomfort.


Answer
A 24yo AAF presents at your primary care office with a slightly
elevated temperature, and headache. She has a PMH significant
for severe asthma. Physical shows a decreased
inspiratory/expiratory ratio as well as nasal polyps. What
recommendations concerning antipyretic and analgesic use are
important to convey before the pt leaves the office?

A) Administer only acetaminophen for fever and
discomfort.
In about 25% of pts with asthma, aspirin and other
nonsteroidal anti-inflammatory drugs (NSAIDs) can
precipitate an asthma attack and should be avoided.
References







Cooper, D. Krainik, A. Lubner, S. Reno, H. Washington Manual or Medical
Therapeutics. 2007
Boon, N. Colledge, N. Walkder, B. Davidson’s principles and practice of med.
2008.
Global Initiative for Chronic Obstructive Lung Disease. http://www.goldcopd.com
Last accessed 6/15/2010.
U.S. Dept. of Health and Human Services. Task Force Recommends Against
Screening for Chronic Obstructive Pulmonary Disease Using Spirometry. Press
Release, March 3, 2008. Agency for Healthcare Research and Quality, Rockville,
MD. http://www.ahrq.gov/news/press/pr2008/tfcopdpr.htm Last accessed 6/12/10.
U.S. Preventive Services Task Force. Screening for Chronic Obstructive
Pulmonary Disease Using Spirometry, Topic Page. March 2008. . Agency for
Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstf/uspscopd.htm Last accessed 6/12/10.
Ferri, Fred. Practical guide to The care of the Medical Patient, 7th ed. Pensilvania,
Elsevier, 2007, pp 777-779.
Global Initiative for Chronic Obstructive Lung Disease, Executive Summary:
Global Strategy for the Diagnosis, Management, and Prevention of COPD, 2008,
accessible at www.goldcopd.com. Last accessed 7/28/2010.
Additional Resources on COPD

Global Initiative for Chronic Obstructive Lung Disease. http://www.goldcopd.com Last accessed 6/15/2010.
U.S. Dept. of Health and Human Services. Task Force Recommends Against Screening for Chronic Obstructive
Pulmonary Disease Using Spirometry. Press Release, March 3, 2008. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/news/press/pr2008/tfcopdpr.htm Last accessed 6/12/10.
U.S. Preventive Services Task Force. Screening for Chronic Obstructive Pulmonary Disease Using Spirometry, Topic
Page. March 2008. . Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstf/uspscopd.htm Last accessed 6/12/10.

Global Initiative for Chronic Obstructive Lung Disease, Executive Summary: Global Strategy for the Diagnosis,
Management, and Prevention of COPD, 2008, accessible at www.goldcopd.com. Last accessed 7/28/2010.