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Chronic Obstructive Pulmonary Disease


Chronic Obstructive Pulmonary Disease Chief s Conference: Kevin L. Gilliam II, M.D. April 16, 2009 Emory Family Medicine What is COPD? It is a syndrome of ... – PowerPoint PPT presentation

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Title: Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease
  • Chiefs Conference
  • Kevin L. Gilliam II, M.D.
  • April 16, 2009
  • Emory Family Medicine

What is COPD?
  • It is a syndrome of progressive airflow
    limitation caused by chronic inflammation of the
    airways and lung parenchyma.
  • The terms chronic bronchitis and emphysema are no
    longer included in the formal definition of COPD,
    although they are still used clinically
  • Emphysema pathologic term used to describe
    destruction of the alveolar capillary membrane
  • Chronic Bronchitis clinical term used to
    describe the presence of cough or sputum
    production for at least a three month duration
    during two consecutive years

Who gets COPD?
  • Smokers
  • Smokers
  • Smokers
  • More than 80 percent of deaths from the disease
    are directly attributable to smoking, and persons
    who smoke are 12 to 13 times more likely to die
    from COPD than nonsmokers.
  • The absolute risk of COPD among active,
    continuous smokers is at least 25 percent

Who else is at risk for getting COPD?
  • People of advancing age
  • Those exposed to secondhand smoke
  • Chronic exposure to environmental or occupational
  • Alpha1-antitrypsin deficiency (typically early)
  • Childhood history of recurrent respiratory
  • Family history of COPD

Whats the Physiology?
  • Related to chronic airway irritation, mucus
    production, and pulmonary scarring.
  • Irritation from environmental pollutants (most
    commonly cigarette smoke) or a genetic
    predisposition leads to airway inflammation,
    which causes increased mucus production and
    decreased mucociliary function
  • The combination of increased mucus and decreased
    mucociliary clearance leads to the hallmark COPD
    symptoms of coughing and sputum production

A Little More Physiology
  • Continued airway irritation and inflammation
    causes scarring within the airways leading to
    airway obstruction and dyspnea
  • Irritation, inflammation, mucus production, and
    scarring also predispose patients to respiratory
    infections which leads them to seek medical
  • Without symptoms many patients will not seek
    medical attention and therefore disease can
    progress before diagnosis or treatment

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Epidemiologically Speaking
  • 10 million adults in the United States have been
    diagnosed with COPD
  • National Health and Nutrition Examination Survey
    (NHANES) suggests that roughly 10 percent of the
    adult U.S. population has evidence of impaired
    lung function consistent with COPD
  • 26 million
  • Underdiagnosed and Underrecognized

Some more Epidemiology
  • More common in women
  • More fatal in Women
  • Secondary to differences in lung size and
    mechanics, womens airways are more
    hyper-responsive to exogenous irritants
  • Although the diagnosis of COPD is often
    overlooked in both populations, it is diagnosed
    even less in women than in men

How is it Diagnosed?
  • Clinical suspicion in patients presenting with
    any of the hallmark symptoms which is then
    confirmed by spirometry.
  • Cough, ?ed sputum production, and dyspnea
  • Especially in patients with a smoking history
  • Since symptoms may not occur until lung function
    is substantially reduced, early detection is
    enhanced by spirometric evaluation of FEV and
  • The National Heart, Lung, and Blood Institute
    recommends spirometry for all smokers 45 years or
    older, particularly those who present with
    shortness of breath, coughing, wheezing, or
    persistent sputum production

More on Diagnosis
  • Physical examination findings are not sensitive
    for the initial diagnosis of COPD
  • Many patients have normal examination findings
  • Features of lung hyperinflation include a widened
    anteroposterior chest diameter, hyperresonance on
    percussion, and diminished breath sounds

Some More on Diagnosis
  • Persistent pulmonary damage can lead to increased
    right-sided heart pressure causing right sided
    heart failure (cor pulmonale)
  • Which can give an accentuated second heart sound,
    peripheral edema, jugular venous distension, and
  • Signs of increased work of breathing include the
    use of accessory respiratory muscles, paradoxical
    abdominal movement, increased expiratory time,
    and pursed lip breathing auscultatory wheezing
    is variable.
  • Other physical findings are occasionally cyanosis
    and cachexia
  • Weight loss is an independent predictor of
    mortality therefore BMI should be followed

A Little More on Diagnosis
  • The stage of the disease suggests the prognosis,
    and follow-up data from longitudinal studies
    indicate that moderate and severe stages of the
    disease are associated with higher mortality
  • Joint guidelines from the American Thoracic
    Society (ATS) and the European Respiratory
    Society (ERS) recommend screening for
    alpha1-antitrypsin deficiency in symptomatic
    adults with persistent obstruction on pfts and
    asymptomatic adults with history of smoking or
    occupational exposure

Just a Smidge More Diagnosis
Then What?
  • Evidence suggests that dyspnea is a better
    predictor of mortality than spirometry in
    patients with COPD
  • MRC dyspnea index has also been combined with
    BMI, FEV1, and exercise capacity (six-minute
    maximum walking distance) into the 10-point BODE
  • Used to predict disease severity, risk of
    hospitalization, and all-cause mortality

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How to Manage Chronic Disease?
  • The major goals of therapy include
  • smoking cessation
  • symptom relief
  • improvement in physiological function and
    limitation of complications
  • i.e. abnormal gas exchange and exacerbations of
    the disease

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How to advance therapy
  • 0 Avoidance of Risk Factor Immunizations
  • 1 PRN short acting bronchodilator
  • 2 Reg treatment with one or more long acting
    bronchodilators, add Rehab
  • 3 Inhaled steroids if repeated exacerbations
  • 4 Oxygen, consider surgery

More on Management
  • Spirometry should be performed at least annually,
    and more frequently if needed, to assess clinical
    status or the response to therapy
  • Abstinence from smoking results in a sustained 50
    percent reduction in the rate of lung-function
    decline in patients with COPD, and smoking
    cessation is the only intervention known to be so
    effective in modifying the disease
  • Annual Influenza Vaccination
  • Pneumococcal Vaccination

What meds to use
  • Inhaled bronchodilators are the foundation of
    pharmacotherapy for COPD because of their
    capacity alleviate symptoms, decrease
    exacerbations of disease, and improve the quality
    of life
  • Albuterol and ipratropium are equally effective
    with regard to bronchodilation, symptom scores,
    and the rates of treatment failure and can be
    used interchangeably for mild disease as the
    first step in a series of measures for treating
    patients with COPD

More on Mgmt
  • Most patients have at least moderate airflow
    limitation when first evaluated, they are likely
    to require regularly scheduled bronchodilation
    and to derive benefit from a long-acting
    bronchodilator as initial therapy
  • Treatment may be initiated with either a
    long-acting anticholinergic agent or a b-agonist,
    since there is little evidence to suggest
    clinically significant differences between
    pharmacologic classes
  • Not appropriate for acute exacerbations

Mgmt Contd
  • The combination of albuterol and ipratropium
    provides greater bronchodilation than either drug
    used alone, and similar benefits are obtained by
    combining long-acting b-agonists with ipratropium

More on Mgmt
  • The appropriate role of inhaled corticosteroids
    in COPD is controversial
  • Trials have demonstrated that treatment with
    inhaled corticosteroids alleviates patients
    symptoms, reduces the frequency of exacerbations,
    and improves health status
  • Patient oriented evidence
  • Exacerbations appear to accelerate the rate of
    lung function decline in COPD
  • Optimize bronchodilator therapy prior to
    initiation of corticosteroids

Supplemental Therapies
  • Pulmonary rehabilitation improves patients
    exercise capacity, reduces dyspnea, improve the
    quality of life, and reduces the number and
    duration of hospitalizations related to
    respiratory disease
  • Hypoxemia develops as a result of a worsening
    ventilationperfusion mismatch, and aggressive
    testing for hypoxemia is critical
  • Studies illustrate mortality is reduced by
    treatment with supplemental oxygen for 15 or more
    hours per day

Therapy contd
  • Medicare guidelines suggest that oxygen therapy
    should be initiated if the resting partial
    pressure of arterial oxygen is 55 mm Hg or lower
    or if the oxygen saturation is 88 percent or less
  • These limitations may not identify all patients
    who would benefit from supplemental oxygen.
  • For example, supplemental oxygen substantially
    improves training intensity and exercise
    tolerance even in patients in whom desaturation
    does not occur during exercise
  • As always treat the patient and not the numbers
  • Worsening hypoxemia during air travel must be
    considered, and a general recommendation is that
    patients requiring oxygen should increase their
    oxygen flow rate by 2 liters per minute during

If nothing else is working
  • Lung-volumereduction surgery can reduce
    hyperinflation and should be considered in
    patients with severe upper-lobe emphysema and
    reduced exercise tolerance who are not faring
    well with medical therapy alone
  • Overall improvement in exercise tolerance but not
    resultant decrease in mortality
  • Single-lung transplantation is an alternative
    surgical option for patients with end-stage
    emphysema who have an FEV1 that is less than 25
  • No significant improvement in survival

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Management of Acute Exacerbations
  • Typically manifest as increased sputum
    production, more purulent sputum and worsening of
    dyspnea. Although infectious etiologies account
    for most exacerbations, exposure to allergens,
    pollutants, or inhaled irritants
  • Use the same medications that are used in chronic
    mgmt to include beta2 agonists and
    anticholinergics (or an increase in their
    dosage), the intravenous administration of
    corticosteroids, antibiotic therapy when
    indicated, and the intravenous administration of
  • Hospitalization may be necessary to provide
    antibiotic therapy, appropriate supportive care
    and monitoring of oxygen status.

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And thats all folks