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CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL PRACTICE GUIDELINES REVIEW WEEK 1: DIAGNOSIS

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Title: CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL PRACTICE GUIDELINES REVIEW WEEK 2 COPD II THERAPY Author: University Health Network – PowerPoint PPT presentation

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Title: CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL PRACTICE GUIDELINES REVIEW WEEK 1: DIAGNOSIS


1
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CLINICAL PRACTICE GUIDELINES REVIEW WEEK 1
DIAGNOSIS
  • AMBULATORY INTERNAL MEDICINE
  • GROUP PRACTICE
  • UNIVERSITY HEALTH NETWORK / MSH
  • SEPTEMBER 2007
  • Prepared by Dr. D. Panisko

2
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3
COPD Guidelines for this Seminar
  • Standards for the diagnosis and treatment of
    patients with COPD a summary of the ATS/ERS
    position paper. Celli BR et al. Eur Respir J
    2004 23 932-46. Full document, with updates,
    available at www.thoracic.org, accessed Sept
    2007
  • Canadian Thoracic Society recommendations for
    the management of chronic obstructive pulmonary
    disease - 2003. ODonnell DE et al. Can Respir J
    2003 10(SupplA) 11A-33A
  • Global Initiative for Chronic Obstructive Lung
    Disease. (GOLD). A collaborative of the NIH and
    WHO. Updated Nov 2006, accessed Sept 2007.
    Available at www.goldcopd.com

4
COPD Diagnosis Objectives
  • After this seminar you should
  • be aware of diagnostic clinical practice
    guidelines for stable chronic COPD
  • be able to define COPD and asthma and outline a
    differential diagnosis
  • be able list important historical and laboratory
    diagnostic features of COPD
  • be able to describe the evidence-based physical
    examination for COPD and airflow limitation

5
COPD I DIAGNOSIS
  • CASE
  • A 61 year old man comes to your clinic as a new
    patient. He had just been admitted to hospital
    for his first exacerbation of COPD. He has
    completed a 10 day antibiotic course and 10 days
    of oral Prednisone. He is now only on an
    ipratropium puffer, 2 puffs qid.
  • How is COPD defined ? What is emphysema ? What
    is asthma ?
  • Why is it important to make a diagnosis of COPD
    (as opposed to asthma) in this patient ?

6
COPD I DIAGNOSIS
  • COPD Definition
  • A preventable and treatable disease state
    characterized by airflow limitation that is not
    fully reversible.
  • The airflow limitation is usually progressive
    and associated with an abnormal inflammatory
    response of the lungs to noxious particles or
    gases, primarily caused by cigarette smoking.
  • Although COPD affects the lungs, it also
    produces significant systemic consequences.
  • Implies post bronchodilator FEV1/FVClt0.7
  • ATS/ERS position paper

7
COPD I DIAGNOSIS
  • COPD traditionally understood as a spectrum -
    components of chronic bronchitis or emphysema.
    The latter may take on revitalized significance
    because of a new approach that considers the
    importance of different phenotypes of COPD.
  • EMPHYSEMA Abnormal permanent enlargement of
    the airspaces distal to the terminal bronchioles,
    accompanied by destruction (lack of uniformity in
    the pattern of airspace enlargement the orderly
    appearance of the acinus and its components is
    disturbed and may be lost) of their walls and
    without obvious fibrosis.

8
Emphysema Pink Puffer !
9
Gross Pathological Changes of Emphysema
10
Microscopic Changes of Emphysema
11
COPD I DIAGNOSIS
  • ASTHMA A chronic inflammatory disorder of the
    tracheobronchial tree, many cells and cellular
    elements play a role, leading to airway
    hyperreactivity and reversible airflow
    limitation. IMPLICATION airway can return to
    normal between attacks or with treatment BUT in
    chronic asthma a condition similar to COPD can
    develop with irreversibility and progression of
    the airflow limitation.
  • It is also important to make a diagnosis of
    asthma as there are differences in therapy for
    asthma and COPD.

12
COPD I DIAGNOSIS
  • CASE (cont.)
  • Can the severity of COPD be staged ?
  • What is the relevance and importance of staging
    a patient with COPD ?

13
GOLD Classification of COPD Severity by
Spirometry
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
14
COPD I DIAGNOSIS
  • What is the relevance and importance of staging a
    patient with COPD ?
  • Stages (GOLD) are currently mainly for
    educational and research purposes
  • Not extensively validated by trials
  • Represent expert consensus opinion
  • Some treatment recommendations exist based on
    patient stage presumably will be further
    validated by clinical trials
  • Canadian guidelines list another severity scale
    but do not recommend treatment on that basis

15
COPD I DIAGNOSIS
  • CASE (cont.)
  • What historical features contribute to the
    diagnosis of COPD ?
  • What are other important features of the hx ?

16
COPD I DIAGNOSIS
  • Important historical information
  • age of onset of symptoms
  • quantify exposure to risk factors i.e.
  • tobacco smoke
  • occupational exposures
  • exposure to outdoor and indoor air pollution
  • presence of liver disease
  • family history
  • childhood respiratory illnesses
  • information that allows a diagnosis of chronic
    bronchitis

17
COPD I DIAGNOSIS
  • Perform respiratory functional inquiry to
    determine current symptom status and to classify
    COPD
  • asymptomatic
  • intermittent symptoms (on exertion,
    nocturnal/sleep)
  • regularly symptomatic
  • severely symptomatic
  • frequency and course of exacerbations

18
COPD I DIAGNOSIS
  • CASE (cont.)
  • What is the differential diagnosis of COPD ?

19
COPD I DIAGNOSIS
  • Differential Diagnosis of COPD
  • Cystic fibrosis, asthma, bronchiectasis, and
    bronchiolitis obliterans (all specific causes of
    airflow limitation) have been conventionally
    excluded from the diagnosis definition of COPD
    and therefore are part of the dx dx.
  • Interstitial lung disease (fibrosis, TB,
    hypersensitivity pneumonitis, sarcoidosis,
    pneumoconioses, etc.) may also present in a
    patient with recurrent shortness of breath,
    exacerbations, and cough.
  • Consider a variety of non-pulmonary causes of
    breathlessness (i.e. CHF)

20
COPD I DIAGNOSIS
  • CASE (cont.)
  • This patient indicates a three year history of
    productive cough, at least on 50 of days, and an
    audible wheeze with SOBOE. His symptoms have
    been progressing over the entire year and he now
    gets SOB with 1 flight of stairs or 3 level
    blocks. He has a 45 pack year smoking history,
    has worked in an office all of his life, and has
    no relevant past medical, childhood, or family
    history.
  • What are indications for screening for alpha-1
    antitrypsin deficiency ?
  • Should this patient be screened?
  • How can screening be performed ?

21
COPD I DIAGNOSIS
  • Screen for alpha-1 antitrypsin deficiency if
    patient
  • is under the age of 45,
  • has a predominance of basilar emphysema,
  • has a minimal smoking history,
  • has a family history of early onset COPD,
  • has a known family history of alpha-1 antitrypsin
    deficiency, or associated liver disease.
  • Screening therefore not indicated in the case.
  • Screening serum assay for alpha-1 antitrypsin
    level 10cc of clotted blood in red top tube (on
    a misc. req. at UHN). For update on genetics of
    COPD see Rabe et al. 2007

22
COPD I DIAGNOSIS
  • CASE
  • What physical exam maneuvers are helpful to
    diagnose airflow limitation ?

Not this one !!!
23
COPD I DIAGNOSIS
  • Evidence Based Physical Exam
  • See 1) Holleman, Rational Clinical Examination
    Series. Does the clinical examination predict
    airflow limitation ? JAMA 1995 273 313-9
  • 2) Straus SE. McAlister FA. Sackett DL. Deeks JJ.
    The accuracy of patient history, wheezing,
    laryngeal measurements in diagnosing obstructive
    airway disease. CARE-COAD1 Group. JAMA 2000
    2831853-7
  • 3)Straus SE. McAlister FA. Sackett DL. Deeks JJ.
    Accuracy of history, wheezing, and forced
    expiratory time in the diagnosis of chronic
    obstructive pulmonary disease. CARE-COAD2 Group.
    J Gen Intern Med 2002 17 684-8

24
COPD I DIAGNOSIS
  • Wheezing Grade A Positive likelihood ratio
    36
  • Barrel Chest B, 10
  • Decreased Cardiac Dullness B, 10
  • Match Test B, 7.1
  • Hyperresonance B, 4.8
  • Forced Expiratory Time gt9 seconds A, 4.8
  • Subxiphoid Apical Impulse B, 4.6
  • Pulsus Paradoxus gt 15mmHg C, 3.7
  • Decreased Breath Sounds B, 3.7
  • Forced Expiratory Time 6 - 9 seconds A, 2.7
  • Many other signs not systematically
    evaluated (diaphragmatic levels, pursed lip
    breathing, use of accessory muscles, indrawing)

25
COPD I DIAGNOSIS
  • Straus et als important contributions to the
    literature have shown that a single physical sign
    is not as useful as a combination of historical
    and physical findings to make a diagnosis of COPD
  • They have published
  • two models
  • What maneuvre is
  • being performed ?

26
COPD I DIAGNOSIS
  • Combined history/physical exam Model I
  • Smoking gt 40 P.Y. (LR 8.3)
  • Self reported history of COPD (LR 7.3)
  • Maximum laryngeal height (LR 2.8)
  • Age gt 45 years (LR 1.3)
  • Combined all 4 LR 220
  • Combined patients with none -LR 0.13

27
COPD I DIAGNOSIS
  • Combined history/physical exam Model II
  • Forced Exp Time gt 9 sec (LR 6.7) Multivariate
    (LR 4.6)
  • Self reported history of COPD (LR 5.6) (LR
    4.4)
  • Wheezing (LR 4.0) (LR 2.9)
  • Smoked longer than 40 pack years (LR 3.3)
  • Male gender (LR 1.6)
  • Age over 65 years (LR 1.6)
  • Combined all 3 LR 59.0
  • Combined patients with none -LR 0.3

28
COPD I DIAGNOSIS
  • CASE (cont.)
  • Physical examination of our patient was only
    relevant for a barrel chest, diffuse occasional
    audible wheezes, and a forced expiratory time of
    7 seconds. Laryngeal height was 5 cm.
  • There were no signs of cor pulmonale.
  • Otherwise, the exam was unremarkable.

29
COPD I DIAGNOSIS
  • CASE (cont.)
  • Which of the following investigations are
    currently indicated ?
  • How will they help in the care of this patient ?
    in the care of other patients with stable COPD
    ?
  • Spirometry
  • Full Pulmonary Function Tests
  • CXR
  • Helical CT of chest
  • Allergy testing
  • O2 saturation (rest, exercise, sleep)
  • ABG

30
COPD I DIAGNOSIS
  • Spirometry Performed for diagnosis, prognosis,
    monitoring of therapy. FEV1, FVC, and ratio most
    important peak flows not recommended.
  • Pulmonary Function Tests Full PFTs not
    necessary for routine dx, usually performed at
    the time of initial dx to establish baseline, may
    be useful for dxdx - i.e to obtain bronchodilator
    reversibility testing to asses for asthma.
  • CXR Useful in exacerbations and for its r/o
    value for other dxdx. Has low sens. and spec.
    for the dx of emphysema, thus not recommended by
    guidelines.

31
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32
COPD I DIAGNOSIS
  • Helical CT of Chest Not necessary for routine
    diagnosis, may be useful for dxdx or for lung
    volume reduction OR.
  • Allergy Testing May have use in asthma, not
    COPD.
  • O2 Sat In severe COPD (stage 2b or 3) useful to
    guide O2 therapy. Nocturnal desaturations are
    probably under diagnosed.
  • ABG Needed to guide long term oxygen therapy
    and to obtain government funding for same. (See
    guidelines for actual criteria for initiation of
    treatment will be discussed next week).

33
COPD I DIAGNOSIS
  • CASE (cont.)
  • The current Canadian guidelines
  • do not emphasize evidence based diagnosis for
    patients with COPD
  • put more emphasis on evaluation of impairment,
    disability with exercise testing, dyspnea
    assessment scales, and quality of life assessment
    scales
  • do not give specific recommendations on how or at
    what point in the patients course these
    evaluations should be used

34
COPD other useful references
  • 2 recent review series on COPD
  • 5 article series on exacerbations
  • Thorax Feb June, 2006
  • 12 article series
  • BMJ May 13th to July 22nd, 2006
  • Excellent recent update
  • Update in Chronic Obstructive Pulmonary Disease
    2006 Rabe KF, et al. Am J Resp Crit Care 2007
    175 1222-1232

35
COPD I DIAGNOSIS
  • Next week
  • COPD II - Therapy
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