Transcript COPD – Margarita Lianeri, PGY-2

COPD
Margarita Lianeri, PGY-2
Thursday, October 1, 2015
TOH AFHT - Melrose Clinic
Overview
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Definition
•
Risk factors
•
who should be screened
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Differential diagnosis
•
Testing and classification
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Management
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Non-pharmacologic management
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Pharmacotherapy
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Acute exacerbation
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End stage COPD
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When to refer
COPD - Definition
progressive, partially reversible airway obstruction
lung hyperinflation
systemic manifestations
increasing frequency and severity of exacerbations
Risk Factors
Differential Diagnosis
★ Tobacco smoke
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Asthma
● Chemicals, fumes, dust
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CHF
α-1 antitrypsin
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TB
1st degree relative
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Obliterative bronchiolitis
low BMI
-
Bronchiectasis
male gender
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Diffuse panbronchiolitis
low socioeconomic status
Hx of pediatric respiratory infections
Testing & Classification
Tests
PFTs
CXR
ECG +/- cardiac echocardiogram
ABG
BMD
sputum cytology
Contraindications to PFTs
Within the last 8 weeks had:
Currently has:
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abdominal, thoracic, or eye surgery
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hemoptysis
-
MI or CP
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increased risk of syncope
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pneumonthorax
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nausea or vomiting
-
intracranial aneurysm
Within the last 6 weeks had:
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lung infection (pneumonia, TB)
PFT Parameters
FVC: Forced vital capacity is the volume of air that
can forcibly be blown out after full inspiration.
FEV1: Forced expiratory volume in 1 second; after
full inspiration.
PEF: Peak expiratory flow measures how fast air is
breathed out from the lungs.
FEV1/FVC (FEV1%) is the ratio of FEV1 to FVC. In
healthy adults this should be approximately 70–85%
(declining with age).
Pulmonary Function Tests
COPD Stage
Spirometry (post-bronchodilator)
Mild
FEV1≥80% predicted, FEV1/FVC <0.7
Moderate
FEV1 50-79% predicted, FEV1/FVC <0.7
Severe
FEV1 30-49% predicted, FEV1/FVC <0.7
Very Severe
FEV1 <30% predicted, FEV1/FVC <0.7 ***or <50% predicted with
chronic respiratory failure present
Example of PFTs - Asthma vs. COPD
Symptoms
COPD stage
Symptoms
Mild (MRC 2)
SOB from COPD when hurrying on the level or walking up a slight hill
Moderate
(MRC 3-4)
SOB from COPD causing the pt to stop after walking approx. 100m on
the level
Severe
(MRC 5)
SOB from COPD resulting:
➢ in the pt being too breathless to leave the house
➢ in breathlessness when dressing or undressing
➢ in presence of chronic respiratory failure
➢ in clinical signs of right heart failure
Management
Nonpharmacologic management
SMOKING CESSATION
Annual flu shot + pneumovax q 5yrs
Exercise training programs
Education (smoking cessation, strategies to avoid dyspnea, self management,
COPD action plan)
Surgery (bullectomy, lung volume reduction, lung transplantation)
Medications
All those respiratory meds...
Asthma meds
aeCOPD
Acute exacerbation of COPD
Increased:
❖ dyspnea
❖ cough
❖ sputum
Common triggers
URTI
Irritants (smoke, dust, etc)
PE
MI
anemia
CHF
systemic infections
Management of aeCOPD
1) Hx and physical to r/o other causes, ABG if low O2sat and CXR
2) Gram stain + culture if very purulent sputum, poor lung function, frequent
exacerbations, antibiotics in the last 3 months
3) PFT if no previous spirometry
4) Inhaled bronchodilator to relieve dyspnea
5) O2 to improve O2 sat
6) Oral or parenteral corticosteroids
7) Antibiotics: purulent exacerbations
Criteria for hospital admission
Marked increase in intensity of symptoms or new physical signs
Severe COPD with failure of an exacerbation to respond to treatment
Presence of serious comorbidities
Frequency of exacerbations
Older age with insufficient home support
End stage COPD
Discuss, document, and periodically re-evaluate wishes about aggressive
treatment interventions
When to refer
Refer to respirologist for:
❖ Uncertain diagnosis
❖ Severe/disproportionate symptoms to spirometry
❖ Accelerated decline of lung function
❖ Onset <40yo
❖ Failure to respond to treatment
❖ Severe/recurrent exacerbations
❖ Complex comorbidities
❖ assessment for pulmonary rehab, home O2, surgical treatment
Putting it all together
Resources for patients (and us)
VIHA (BC) patient info
Living Healthy Champlain
Lung association
NIH
Follow-up
❖ Monitor exposure to risk factors
❖ Monitor disease progression and development of complications
❖ Monitor pharmacotherapy and other medical treatment
❖ Monitor exacerbation history
Goals of treatment:
- prevent progression
- prevent exacerbations
- relieve symptoms
- minimize side effects of medications
10 common errors in management of COPD
1. Not making the diagnosis
2. Not checking objective measures of the patient’s airflow obstruction
3. Not emphasizing smoking cessation
4. Not teaching/reviewing inhaler technique
5. Not teaching/reviewing when the inhaler should be used (i.e. purpose)
6. Overuse or underuse of supplemental oxygen
7. Fear of prescribing oral steroids
8. Missing the dx of COPD because of ‘clear lung fields’ on CXR
9. Overusing Abx to treat aeCOPD
10. Not considering environmental factors in managing COPD
References
http://ccfpprep.com/2014/11/10/copd-canadian-thoracic-society-2007/
http://wiki.ubc.ca/Course:PostgradFamilyPractice/ExamPrep/99_Priority_Topics/COPD
http://www.who.int/respiratory/copd/GOLD_WR_06.pdf
https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000025.htm
http://www.lung.ca/copd
http://www.thoracic.org/patients/patient-resources/resources/copd-medicines.pdf
http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_2015_Feb18.pdf
http://ccfpprep.com/2014/11/10/copd-canadian-thoracic-society-2007/
http://familydoctor.org/familydoctor/en/diseases-conditions/chronic-obstructive-pulmonary-disease.printerview.all.html
http://www.nhlbi.nih.gov/health/educational/copd/event-listing/awareness-month/materials-resources.htm