Chronic Obstructive Pulmonary Disease COPD - PowerPoint PPT Presentation

Loading...

PPT – Chronic Obstructive Pulmonary Disease COPD PowerPoint presentation | free to view - id: 5fbb0-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Chronic Obstructive Pulmonary Disease COPD

Description:

Pulmonary Hypertension in COPD. Source: GOLD 2007. Diagnosis and Assessment. of COPD ... Few RCTs, no evidence for improvement in mortality but can relieve symptoms ... – PowerPoint PPT presentation

Number of Views:312
Avg rating:3.0/5.0
Slides: 50
Provided by: david207
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Chronic Obstructive Pulmonary Disease COPD


1
Chronic Obstructive Pulmonary Disease (COPD)
  • PGY-1 Seminar
  • David Thom, MD, PhD
  • October 26, 2007

2
Learning Objectives To be able to
  • Conduct a relevant P.E. and interpret the
    findings in a patients with suspected COPD
  • Identify 4 medication and 3 non-medication
    interventions for managing COPD
  • Identify 3 steps in the outpatient medical
    management for acute exacerbation of COPD and
    criteria for hospitalization

3
Overview
  • Definition, epidemiology and pathophysiology
  • Diagnsosis and Assessment (2 cases)
  • Management
  • Risk factor reduction
  • Stable chronic COPD
  • Acute exacerbations of COPD

4
Definition of COPD
  • COPD is a preventable and treatable chronic lung
    disease characterized by airflow limitation that
    is not fully reversible.
  • The airflow limitation is usually progressive and
    associated with an abnormal inflammatory response
    of the lung.

Adapted from the Global Initiative for Chronic
Obstructive Lung Disease 2007
5
Epidemiology of COPD
  • COPD is a leading cause of mortality worldwide
    and projected to increase in the next several
    decades.
  • COPD mortality trends generally track several
    decades behind smoking trends.
  • In the US and Canada, COPD mortality for both men
    and women have been increasing.
  • In the US in 2000, the number of COPD deaths was
    greater among women than men.

6
Percent Change from 1965 in Age-Adjusted Death
Rates, U.S., 1965-1998
Coronary Heart Disease
Stroke
Other CVD
COPD
All Other Causes
2.5
2.0
1.5
1.0
0.5
35
59
64
163
7
0
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
Source NHLBI/NIH/DHHS
7
COPD Mortality by Gender,U.S., 1980-2000
Number Deaths x 1000
Source US Centers for Disease Control and
Prevention, 2002 cited in GOLD 2007
8
Risk Factors for COPD
Nutrition
Infections
Socio-economic status
Aging Populations
9
Pathophysiology of COPD
  • Chronic inflammation, bronchial wall edema,
    mucous secretion, hyperinflation and air
    trapping
  • Increase in proteinases compared to
    antiproteinases and in free radicals leading to
    parenchymal destruction
  • Changes in pulmonary vasculature leading to
    ventilation-perfusion mismatching, pulmonary
    hypertension, cor pulmonale

10
(No Transcript)
11
Pathogenesis of COPD
Cigarette smoke Biomass particles Particulates
Host factors Amplifying mechanisms
LUNG INFLAMMATION
Anti-oxidants
Anti-proteinases
Oxidative stress
Proteinases
Repair mechanisms
COPD PATHOLOGY
Source GOLD 2007
12
Changes in Small Airways in COPD Patients
Inflammatory exudate in lumen
Disrupted alveolar attachments
Thickened wall with inflammatory cells -
macrophages, CD8 cells, fibroblasts
Peribronchial fibrosis
Lymphoid follicle
Source COLD 2007
13
Changes in Lung Parenchyma in COPD
Alveolar wall destruction
Loss of elasticity
Destruction of pulmonary capillary bed
? Inflammatory cells macrophages, CD8
lymphocytes
Source GOLD 2007
14
Pulmonary Hypertension in COPD
Chronic hypoxia
Pulmonary vasoconstriction
Muscularization Intimal hyperplasia Fibrosis Obli
teration
Pulmonary hypertension
Cor pulmonale
Edema
Death
Source GOLD 2007
15
Diagnosis and Assessment of COPD

16
Patient LG
  • 54 year old man with a 80 pack-year smoking
    history, presents with dyspnea while climbing
    stairs and an occasional, non-productive cough
  • What would you look for/expect on exam?

17
Patient LG Examination
  • Diminished breath sounds on auscultation
  • Forced expiratory time of gt6 seconds
  • Decreased I/E ratio
  • Increased thoracic circumference and decreased
    change with respiration
  • Increased resonance to percussion

18
Patient EC
  • 62 year woman with 40 p-yr history presents
    with chronic cough for 3 months, productive of
    clear to light yellow phlegm
  • What would you look for/expect on exam?

19
Patient EC
  • Rhonchus breath sounds
  • 1 ankle edema

20
Patients LG and EC
  • What tests would you order?

21
Diagnosis and Assessment
  • A clinical diagnosis of COPD should be considered
    in any patient who has dyspnea, chronic cough
    or sputum production, and/or a history of
    exposure to risk factors for the disease.
  • The diagnosis should be confirmed by spirometry.
    A post-bronchodilator FEV1/FVC lt 0.70 confirms
    the presence of airflow limitation that is not
    fully reversible.

22
Spirometry Normal and Patients with COPD
23
Classification of COPD Severity by Spirometry
post Bronchodilator
  • Stage I Mild FEV1/FVC lt 0.70
  • FEV1 gt 80 predicted
  • Stage II Moderate FEV1/FVC lt 0.70
  • 50 lt
    FEV1 lt 80 predicted
  • Stage III Severe FEV1/FVC lt 0.70
  • 30 lt
    FEV1 lt 50 predicted
  • Stage IV Very Severe FEV1/FVC lt 0.70
  • FEV1 lt 30 predicted
    or
  • FEV1 lt 50 predicted plus
  • chronic respiratory failure

Adapted from the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) 2007
24
Patient LG Test Results
  • CXR Hyperinflation and increased lucency
  • FEV1/FEV.55
  • FEV140

25
Patient EC Test Results
  • CXR peribronchial thickening
  • FEV1/FEV.60
  • FEV155

26
Patient LG
  • 54 year old man with a 80 pack-year smoking
    history, presents with dyspnea while gardening,
    occasional, non- productive cough
  • What is his condition?

27
Patient EC
  • 62 year woman with 40 p-yr history presents
    with chronic cough for 3 months, productive of
    clear to light yellow phlegm
  • What is her condition?

28
Differential Diagnosis COPD and Asthma
COPD
ASTHMA
  • Onset early in life (often childhood)
  • Symptoms vary from day to day
  • Symptoms at night/early morning
  • Allergy, rhinitis, and/or eczema also present
  • Family history of asthma
  • Largely reversible airflow limitation
  • Onset in mid-life
  • Symptoms slowly progressive
  • Long smoking history
  • Dyspnea during exercise
  • Largely irreversible airflow
  • limitation

29
Management of COPD

30
GOALS of COPD MANAGEMENT
  • Relieve symptoms
  • Prevent disease progression
  • Improve exercise tolerance
  • Improve health status
  • Prevent and treat complications
  • Prevent and treat exacerbations
  • Reduce mortality

31
General Points
  • Only smoking cessation and O2 therapy (when
    indicated) have been shown to prolong survival
  • Other therapies aimed at relieving symptoms,
    improving quality of life, reducing
    exacerbations and need for hospitalizations

32
Risk Factor Reduction
  • Smoking cessation (prolongs survival)
  • Avoid exposure to second hand cigarette smoke
  • Reduction of exposure to indoor and outdoor
    pollution
  • Influenza vaccine
  • Pneumococcal vaccines

33
Brief Strategies to Help the Patient Willing to
Quit Smoking
  • ASK Systematically identify all tobacco
    users at every visit.
  • ADVISE Strongly urge all tobacco users to
    quit. (even a brief (3-minute) period of
    counseling to quit results in smoking
    cessation in 5-10 of patients.)
  • ASSESS Determine willingness to make a
    quit attempt (stages of change).
  • ASSIST Aid the patient in quitting.
  • ARRANGE Schedule follow-up contact.

34
IV Very Severe
III Severe
II Moderate
I Mild
Add regular treatment with one or more
long-acting bronchodilators (when needed) Add
rehabilitation
Add inhaled glucocorticosteroids if repeated
exacerbations
Add long term oxygen if chronic respiratory
failure. Consider surgical treatments
35
Treatment of Stable COPD Bronchodilators
  • Bronchodilator medications are central to the
    symptomatic management of COPD (Evidence A).
  • They are given on an as-needed basis or on a
    regular basis to prevent or reduce symptoms and
    exacerbations.
  • The principal bronchodilator treatments are
    ß2- agonists and anticholinergics used singly or
    in combination
  • Regular treatment with long-acting
    bronchodilators is more effective and convenient
    than treatment with short-acting bronchodilators

36
Treatment of Stable COPD Inhaled Glucocorticoids
  • Consider adding regular treatment with inhaled
    glucocorticosteroids to bronchodilator treatment
    is for symptomatic COPD patients with an FEV1 lt
    50 predicted (Stage III and IV) and repeated
    exacerbations (Evidence A).
  • An inhaled glucocorticosteroid combined with a
    long-acting ß2-agonist is more effective than the
    individual components (Evidence A).

37
Treatment of Stable COPDOther Medications
  • Chronic oral Prednisone
  • Use in chronic COPD is controversial. No effect
    on survival. May improve symptoms and reduce
    hospitalizations in some patients already at
    maximum treatment
  • Mucolytics Expectorants (SSKI, guafenesin)
  • Relives symptoms from copious, viscous
    secretions
  • Oral Theophylline
  • If inhalers not sufficient
  • Side effects common

38
Treatment of Stable COPD Home Oxygen Therapy
  • gt 15 hours/day reduces mortality
  • Criteria for O2 therapy
  • Pa O2 lt 55 mm Hg (O2 saturation lt 88) at rest
    or during exercise or sleep or
  • Pa O2 lt 60 mm Hg and hematocrit gt52
  • Bipap when sleeping may provide additional
    improvement

39
Treatment of Stable COPDPulmonary
Rehabilitation and Patient Education
  • Typically includes exercise, education and
    psychological support
  • Shown to improve symptoms, exercise capacity,
    reduce use of medical care, reduce anxiety and
    depression

40
Treatment of Stable COPDSurgery
  • Primarily for patients with emphysema
  • Few RCTs, no evidence for improvement in
    mortality but can relieve symptoms
  • Improves QOL and exercise capacity in patients
    with primarily upper lobe disease, low exercise
    capacity, and FEV1 between 20 and 30
  • Lung transplantation

41
Treatment of Acute Exacerbations of COPD

42
Acute Exacerbations of COPD
  • The most common causes of an exacerbation
    are infection of the tracheobronchial tree and
    air pollution, but the cause of about
    one-third of severe exacerbations cannot be
    identified.

43
Outpatient Treatment of Acute Exacerbations
Bronchodilators
  • Inhaled bronchodilators (particularly
    inhaled ß2-agonists with or without
    anticholinergics) are effective treatment
    for exacerbations of COPD (LOE A).

44
Outpatient Treatment of Acute Exacerbations
Prednisone
  • Oral prednisone is effective treatment for
    exacerbations of COPD (LOE A).

45
Outpatient Treatment of COPD Exacerbation
Antibiotics
  • Surprisingly little evidence of efficacy
  • Typically use in patients with purulent sputum
    or other signs of infection
  • Amoxicillin, doxycycline, azithromycin,
    trimethoprim-sulfa are reasonable first line
    choices

46
Indications for Hospital Admission of Patient
with Acute Exacerbation
  • Resting dyspnea after initial treatment
  • Lack of response to initial treatment
  • Significant co-morbid conditions)
  • Severe underlying COPD/prior ICU ventilation
    for exacerbations
  • New physical signs (e.g., new peripheral edema)
  • Diagnostic uncertainty
  • Insufficient home support

47
Inpatient Treatment of Acute Exacerbations
  • Oxygen to keep O2 sat gt90
  • Nebulizer treatments with bronchodilators
  • Steroids (LOE A)
  • (40 to 60 mg daily for 7 to 14 days, IV or PO)
  • Antibiotics (LOE B)
  • Typically ceftriaxzone (1 gram IV q 24 h)
    doxycycline (100 mg po q 12 h) at SFGH
  • Fluids

48
  • The End
  • Thank you

49
(No Transcript)
About PowerShow.com