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Management of Chronic Airflow Obstruction

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COPD emphysema/chronic obstructive bronchitis. Bronchiectasis cystic fibrosis ... DX: Chronic obstructive bronchitis and emphysema. http://www.goldcopd.com ... – PowerPoint PPT presentation

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Title: Management of Chronic Airflow Obstruction


1
Management of Chronic Airflow Obstruction
  • J.R. Sheller, M.D.
  • Allergy, Pulmonary Critical Care Medicine

2
Chronic Airflow Obstruction
  • Asthma
  • COPD emphysema/chronic obstructive bronchitis
  • Bronchiectasis cystic fibrosis
  • Obliterative bronchiolitis

3
  • 12.1 million adults ages 25 and older reported
    being diagnosed with COPD 21 million asthmatics
  • Total estimated cost of COPD 32.1 billion,
    asthma was 13.8
  • COPD is the fourth leading cause of death in the
    U.S. and is projected to be the third leading
    cause of death by the year 2020.
  • 5000 deaths/yr from asthma

4
(No Transcript)
5
Spirometry
6
Functional residual capacity
7
100
FEV1 () max
50
Disability
Death
80
20
40
Time (yrs)
8
100
FEV1 ()
50
Disability
Death
80
20
40
Time (yrs)
9
Smoking Cessation
  • Counseling
  • Has patient thought about stopping?
  • Rehearse reasons to quit
  • Offer to help
  • Group therapy quitting sessions Cancer Society,
    Heart Assoc., Lung Assoc.
  • Medications
  • Wellbutrin
  • Nicotine
  • Clonidine

10
Bronchodilators
  • Beta2 adrenergic agonists
  • By metered dose inhaler
  • By nebulizer
  • Short acting albuterol, terbutaline rescue
    medicine
  • Long acting salmeterol, formoterol
  • Not used for rescue

11
Anticholinergics
  • Ipratropium
  • Tiatropium

Work best in COPD Viral exacerbations of asthma
in children
12
Theophylline
  • Methylxanthines adenosine antagonists,
    phosphodiesterase inhibitors, induces histone
    deactylase
  • Narrow therapeutic window
  • Not important in emergency
  • May help in difficult cases
  • Phosphodiesterase 4 inhibitor

13
Antiinflammatory RX
  • Can improve function
  • Can improve symptoms
  • Uncertain if it alters natural history
  • May affect structural changes (remodeling)

14
Inhaled Corticosteroids
  • Topically active
  • Delivered to the airway
  • First pass liver metabolism reduces systemic
    availability
  • Unknown mechanism of action

15
Inhaled Corticosteroids
  • Theoretical
  • suppression of adrenals
  • growth retardation in kids
  • Known
  • oral thrush and vocal cord dysfunction
  • Increased cataracts
  • Increased loss of bone

16
  • Beclomethasone 2 puffs QID
  • Triamcinalone 2 inhalations TID
  • Fluticasone 2 inhalations BID (3 strengths)
  • Flunisolide 2 inhalations BID
  • Budesonide 2 inhalations BID

Convenient, cheap
17
Leukotriene Modifiers
  • Zileuton 5 Lipoxygenase inhibitor
  • Receptor antagonist
  • Zafirlukast 20mg BID
  • Montelukast 10mg QD

18
COPD
  • 72 year old smoker for 60yrs
  • Cough, sputum production, dyspnea
  • FEV1 33 predicted DLCO 25 predicted
  • Rhonchi, wheezes, pedal edema

DX Chronic obstructive bronchitis and emphysema
http//www.goldcopd.com/
19
COPD Rx
  • Smoking cessation
  • Inhaled ipratropium, beta agonist using MDI
  • Long acting beta adrenergic - salmeterol
  • Flu vaccine, pneumovax
  • Antimicrobials for increased sputum (amoxicillin,
    doxycycline, macrolides, trimethoprim/sulfa)
  • Inhaled corticosteroids controversial
  • Avoid oral steroids

20
  • Calls with low grade fever, dyspnea, ankle edema
  • Admitted to hospital with SaO2 75
  • Oxygen by nasal prongs
  • BiPAP (non invasive ventilation)
  • Systemic steroids iv methylprednisolone,
    convert to oral (60mg prednisone)
  • Nebulized ipratropium/albuterol
  • Pneumovax, influenza vaccine

21
Home Oxygen
  • SaO2 lt89 (or pulmonary hypertension, Hct gt55,
    CHF)
  • Should be used 24hrs day
  • After 6 weeks, recheck sats (50 of patients no
    longer need it)

Home oxygen tethers patients, causing
deconditioning Pulmonary rehab, activity are
important
22
  • 35 year old female with episodic cough, wheezing,
    dyspnea after jogging
  • Childhood history of asthma
  • Atopic (hay fever)
  • Normal exam
  • FEV1 normal FEV1/FVC reduced

23
  • Albuterol MDI prior to exercise
  • Medication works, but she uses it each day
  • Add inhaled steroids
  • Now awakening at night with cough
  • Add long acting beta agonist (salmeterol,
    formoterol or combination, eg Advair, Symbicort)
  • Rehearse inhaler use, action plan
  • Allergy/Pulmonary consultation

http//www.nhlbi.nih.gov/about/naepp/
24
  • Still having problems with dyspnea, uses
    albuterol several times a day
  • GERD, Sinus disease
  • Increase inhaled steroids
  • Add leukotriene modifier Montelukast,
    zafirlukast receptor blockers Zileuton
    inhibitor of 5-lipoxygenase
  • Consider theophylline
  • Anti IgE (omalizumab)

25
  • Has symptoms of URI, using albuterol every 2hrs,
    not getting relief
  • ED Rx
  • Oxygen
  • Continuous albuterol
  • Intravenous methylprednisolone 125mg
  • Ipratropium
  • Mg may help those with most severe obstruction
  • Measure PEFR, FEV1, pulsus paradoxus
  • Admit in 2hrs if no improvement

26
Risk of death in Asthma
  • Frequent hospitalizations
  • Intubated for asthma
  • Poor perception of airflow obstruction
  • Frequent albuterol rescue medication use
  • Psychosocial problems

27
Treatment Scheme
  • Mild intermittent b-agonists
  • Mild persistent inhaled steroids
  • Moderate salmeterol, more inhaled
    steroids, leukotriene modifiers
  • Severe theophylline, oral steroids, anti
    IgE

28
(No Transcript)
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