COPD/ASTHMA - PowerPoint PPT Presentation

Loading...

PPT – COPD/ASTHMA PowerPoint presentation | free to view - id: 4702f9-ZTZlM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

COPD/ASTHMA

Description:

COPD/ASTHMA Carl Boethel, MD January 11, 2011 Oximetry testing Overnight oximetry for nocturnal oxygen SpO2 less than 89% for 5% of recording time Pulmonary Exercise ... – PowerPoint PPT presentation

Number of Views:154
Avg rating:3.0/5.0
Slides: 53
Provided by: cboe2
Category:

less

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

Title: COPD/ASTHMA


1
COPD/ASTHMA
  • Carl Boethel, MD
  • January 11, 2011

2
Definitions
  • Asthma
  • Characterized by airway obstruction that is
    reversible, airway inflammation and airway
    hyperreactivity
  • COPDChronic Obstructive Pulmonary Disease
  • Characterized by airway obstruction that is
    progressive, persistent, preventable, and
    associated with airway inflammation and can be
    partially reversible

3
Similarities
  • Airway inflammation
  • Narrowing of the airway
  • Bronchoconstriction

4
Inflammation
  • Asthma
  • Mediated by Eosinophils
  • Affected by Mast Cells along airway epithelium
  • Most is IgE mediated
  • Reversible with therapy
  • COPD
  • Mediated by Neutrophils
  • Response to smoking
  • Rate of progression can be slowed

5
Asthma
Intact epithelium
No cellular infiltrate or collagen deposition
Goblet cell hyperplasia
Thick basement membrane
Airway of person without Asthma
Inflamed airway of Asthmatic
NEJM, 2001
6
Prevalence of Asthma
  • 7 of all Americans have current Asthma1
  • Estimates of 300 million persons worldwide2
  • MgtF prior to puberty
  • FgtM after puberty3
  1. The state of asthma in America.
    http//www.asthmainamerica. 2009
  2. Pearce etal. Thorax 200762758-66.
  3. Morbidity and Mortality Report, National Center
    for Health Statistics (NCHS), U.S. CDC, 2003

7
Death and Hospitals
  • 5000 deaths from Asthma
  • 500K hospitalizations
  • 10 million outpatient visits yearly
  • 2 million ER visits, 25 of all ER visits
  • Death rate from Asthma increased 50 since 1965
  • Increased 80 in children under 19 years old

New Asthma Estimates Tracking Prevalence,
Health Care and Mortality, NCHS, CDC, 2001
8
Asthma Capitals
  • Cities with highest prevalence and likelihood for
    asthma
  • Scored on pollen counts, smoking rates,
    hospitalizations for asthma, air quality, access
    to specialists, deaths from asthma
  • 1 Richmond, VA
  • In Texas
  • 21 San Antonio
  • 22 McAllen
  • 39 El Paso
  • 61 Houston

www.asthmacapitals.com
9
Asthma in the patient
  • Symptoms
  • Breathlessness
  • Wheezing
  • Cough
  • Chest tightness
  • Temporality at night and early morning

10
Triggers
  • Animal, Plant and Bacterial Proteins
  • Antibiotics
  • Irritant Gases
  • Cold or Dry Air
  • Tobacco Smoke
  • Viral infections
  • Emotional Stress

11
Various Causes Worldwide
12
Patient work-up
  • History
  • Physical exam
  • Chest X-Ray
  • Spirometry
  • Peak Flow
  • Methacholine Challenge

13
History
  • When do symptoms occur?
  • What triggers symptoms?
  • Work environment? Chemicals?
  • Smoking history or exposure
  • Pets in house
  • Carpet in house
  • Child in Daycare or cared for at home
  • Family history of Asthma or Atopy

14
Physical Exam
  • Wheezing
  • High pitched 400Hz
  • Hissing or shrill whistle
  • Suggest airway narrowing
  • Edema
  • Bronchospasm
  • Mucous
  • Heard on inspiration and expiration

15
Chest X-Ray
16
Spirometry
  • Spirometry may be normal
  • Often see Airflow obstruction
  • FEV1/FVC ratio lt70
  • Reversibility with bronchodilation
  • Improvement in FEV1 or FVC of 200mL and 12 from
    baseline

Eur Respir J 2005 26 319338
17
Peak Flow
  • Can be used to determine airway hyperreactivity
  • Decrease in Peak Flow with exacerbation of Asthma
  • Reliability to diagnose asthma is controversial

18
Methacholine Challenge
  • Methacholine
  • Fast and easily reversible bronchoconstrictor
  • Incremental doses of methacholine are given with
    serial Spirometric readings
  • Decrease of 20 indicative of bronchoconstriction
  • Sensitivity of test is excellent
  • Specificity of test is very poor

19
Chronic Obstructive Pulmonary Disease
20
COPD-Process
  • Genetic Predisposition
  • Exposure to Smoking
  • Only 15-25 of smokers develop COPD
  • Alpha-1-antitrypsin deficiency is most common
  • Airway obstruction
  • Mucus hypersecretion
  • Emphysema (disrupted alveolar attachements)
  • Mucosal and peribronchial fibrosis and
    inflammation

21
COPD-Pathogenesis
  • Respiratory Bronchiolitis is precursor
  • Alveolar macrophages
  • Proteases
  • Cytokine mediators
  • Kaolinite (Aluminum Silicate)
  • Brown pigmented cytoplasmic inclusions
  • Found in macrophages of COPD patients
  • Common in agricultural clay soils
  • High in Tobacco producing states

Girod et al. Chest 2005
22
COPD-Prevalence
  • 12.6 million US citizens affected
  • Age adjusted death rates up 163 since 1965
  • Comparatively stroke and heart disease have
    declined over the same time
  • Women account for 63 of COPD cases
  • 70 of COPD patients are younger than 65
  • COPD Asthma Diabetes in numbers between ages
    45-64

Lethbridge-Cejku et al. NHIS 2004.
23
GOLD Guidelines
  • Global Initiative for Chronic Obstructive Lung
    Disease
  • Evidence based guidelines for combating COPD
  • Smoking Cessation
  • Patient Education
  • Diagnostic parameters for research and treatment
    purposes
  • Outline stepwise treatment based on severity of
    lung injury

24
COPD in the Patient
  • Symptoms
  • Dyspnea
  • Cough with and without phlegm
  • Fatigue
  • Reduction in Activities of Daily Living
  • Misperception and Denial are barriers to
    diagnosis and treatment
  • Male or Female gt 45 years old

25
Patient work-up
  • History
  • Physical Exam
  • Spirometry
  • Oximetry testing
  • Blood Gases
  • Chest X-Ray

26
History
  • Dyspnea history
  • Onset of symptoms does not occur until FEV1 is
    down 50
  • What makes it worse?
  • What makes it better?
  • Family history of COPD
  • Smoking history measured in pack years
  • Occupational history
  • Military history

27
Fletcher et al. Br Med J. 197711645-1648
28
Physical Exam
  • Pink Puffer
  • Blue Bloater

29
Physical exam continued
  • Wheezing
  • Prolonged bronchial breath sounds
  • Clubbing
  • Cyanosis

30
Clubbing
  • Distal phalanx is rounded and bulbous
  • The nail plate is convex
  • Angle between the nail plate and proximal nail
    fold is 180o or more
  • Lung cancer
  • Chronic Hypoxia
  • Bronchiectasis
  • Cystic Fibrosis

31
Cyanosis
  • Blue discoloration of the nails, can also be seen
    on the lips and skin
  • Acute or Chronic
  • Associated with Hypoxia
  • Can be toxin induced

NLM Website
32
Spirometry
  • FEV1/FVC ratio lt70
  • Incomplete or
  • no response to bronchodilator

33
Spirometric Classification of COPDSeverity Based
on Post-Bronchodilator FEV1
  • Stage I Mild FEV1/FVC lt 0.70
  • FEV1 80 predicted
  • Stage II Moderate FEV1/FVC lt 0.70
  • 50 _ FEV1 lt 80 predicted
  • Stage III Severe FEV1/FVC lt 0.70
  • 30 _ 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

GOLD 2009.
34
Oximetry testing
  • Overnight oximetry for nocturnal oxygen
  • SpO2 less than 89 for gt5 of recording time
  • Pulmonary Exercise tests for desaturation and
    titration
  • SpO2 less than 88 during exercise
  • Pulse Oximetry at rest
  • SpO2 less than 89
  • Nocturnal oxygen is one of the only things that
    is proven to prolong life in COPD

Nocturnal Oxygen Therapy Trial. Ann Intern Med
198093391398.
35
Arterial Blood Gas
  • PaO2 less than 55mmHg necessary to get oxygen
    for patient
  • PaCO2 greater than 52mmHg qualifies for BIPAP for
    treating hypercapnia

36
Chest X-Ray
  • Hyperexpanded lung fields
  • Flattened diaphragms
  • Inferiorly displaced heart
  • Emphysematous changes

37
Treatment
  • Asthma
  • COPD
  • Remove offending triggers
  • Patient Education
  • Medications
  • Annual flu vaccine
  • Smoking Cessation!!!!
  • Patient Education
  • Flu vaccine
  • Pneumonia vaccine
  • Medications
  • Pulmonary Rehabilitation

38
Medications
  • Short Acting Bronchodilators
  • Act on Beta-2 receptors in the bronchi
  • Nebulizers, meter dose inhalers, tablets, syrup
  • Albuterol
  • Levalbuterol
  • Metaproterenol
  • Pirbuterol

39
Meter Dose Inhaler
40
Spacer
41
Inhaled Corticosteroids
  • Act to reduce inflammation
  • Not intended for acute exacerbations
  • Come in nebulizer, dry powder, and MDI
  • Beclomethasone
  • Budesonide
  • Ciclesonide
  • Flunisolide
  • Fluticasone
  • Mometasone
  • Triamcinolone

42
Long Acting Beta-2 Agonists
  • ArformoterolLiquid nebulizer
  • Formoterolcomes in Dry powder capsule and
    nebulizer forms
  • SalmeterolPowder inhaler
  • FDAContraindicated for use alone in all ages.
    Should only be used in conjunction with inhaled
    corticosteroids.

Chowdhury and Pan. NEJM 2010
43
Combination Medications
  • Budesonide with formoterolcomes as an MDI
  • Fluticasone with salmeterolMDI or dry powder

44
Leukotriene Modifiers
  • Cause bronchodilation by reducing airway
    inflammation by binding to leukotriene receptors
  • Montelukast, Zafirlukast, and Zileuton

45
Anti IgE therapy
  • Omalizumab
  • Anti IgE monoclonal antibody
  • Binds to IgE that recognizes the surface of mast
    cells.
  • Administered subcutaneously every 2-4 weeks
  • Indicated in patients who have failed all other
    therapies
  • Used only in Asthma management

46
Oral Corticosteroids
  • Due to side effects they are not recommended for
    chronic treatment of Asthma or COPD
  • May be used in acute exacerbations for short
    bursts of 14 days or less

47
Anticholinergics
  • Bind to Muscarinic receptors in the airway and on
    bronchial smooth muscle to reduce inflammation
    and decrease bronchial hyperreactivity.
  • Ipratropium
  • Half life 4 hours
  • Tiotropium
  • Half life up to 24 hours
  • May now be used as a STEP UP in maintenance
    therapy of asthma

Peters et al. NEJM 2010
48
Theophylline
  • Phosphodiesterace inhibitor similar to caffeine
  • Naturally found in tea
  • Provides bronchodilitation
  • Narrow therapeutic window
  • Side effects include tachycardia, anxiety and
    palpitations
  • Not highly recommended

49
Varenicline
  • Nicotine receptor agonist-antagonist
  • Indicated to treat cigarette smoking
  • 44 efficacy at stopping smoking in clinical
    trials
  • Expense and coverage is a problem

50
Hospitalization
  • IV Corticosteroids
  • Inhaled ß-2 agonists
  • Oxygen
  • Heliox
  • 80/20 mixture Helium to Oxygen
  • Improves airflow within the first hour of
    therapy1
  • IV Magnesium
  • Improves FEV1 in severe asthma attacks2
  • IV Magnesium and Heliox not well studied in COPD

1. Ho et al. Chest 2003, 2. Silverman et al.
Chest 2002.
51
NIPPV and Mechanical Ventilation
  • Positive Pressure Therapy
  • NIPPV
  • CPAP
  • Improve work of breathing
  • Mechanical Ventilation
  • Allow for long exhalation
  • Keep Resp rate low (11-14 breaths per minute)
  • Monitor of hyperinflation and auto-PEEP
  • May require paralysis

Rodrigo et al. Chest 2004.
52
Conclusion
  • COPD and Asthma are similar yet different
  • Effect different patient populations
  • Disease course is similar
  • Cause much loss of life and quality of life
  • Treatments are similar
About PowerShow.com