Respiratory Lecture (Johnson) Copd

Front 1

Assess and Monitor Disease Classification of COPD

Back 1

Stage 0 At Risk
Stage I Mild COPD
Stage II Moderate COPD
Stage III Severe COPD
Stage IV Very Severe COPD

Front 2

stage 0 - at risk

Back 2

Normal spirometry
+/- Chronic symptoms (cough, sputum, production)

Front 3

stage 1 - mild COPD

Back 3

FEV1/FVC <70%
FEV1 >80% predicted
With or without chronic symptoms (cough, sputum production)
(FEV1/FVC should be >70)

Front 4

stage 2 - moderate COPD

Back 4

FEV1/FVC <70%
50% <FEV1 <80% predicted
With or without chronic symptoms (cough, sputum production)
** predicted should be ~75)

Front 5

stage 3- severe COPD

Back 5

FEV1/FVC <70%
30% <FEV1 <50% predicted
With or without chronic symptoms (cough, sputum production)

Front 6

stage 4- very severe COPD

Back 6

FEV1/FVC <70%
FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure

Front 7

Assess: Who Has Early Stages And Who Do You Test?

Back 7

Test patients with:
chronic cough and sputum
exposure to risk factors
even if no dyspnea

Early Stage:
airflow limitation that is not fully reversible
with or without the presence of symptoms

Front 8

Surface area of diffusion goes down, resistance goes up, more work to breath, tires easily (emphysema)

Back 8

true

Front 9

cough

Back 9

intermittent or daily
present throughout day- seldom only nocturnal

Front 10

sputum

Back 10

Any pattern of chronic sputum production

Front 11

Dyspnea

Back 11

Progressive and Persistent
"increased effort to breathe" "heaviness" "air hunger" or "gasping"
Worse on exercise
Worse during respiratory infections

Front 12

exposure to risk factors

Back 12

Tobacco smoke
Occupational dusts and chemicals
Smoke from home cooking and heating fuels

Front 13

Assess: Spirometry to Diagnose

Back 13

FEV1/FVC <70% and a postbronchodilator FEV1 <80% predicted confirms the presence of airflow limitation that is not fully reversible.
Must have access to spirometry

Front 14

Assess: Measure Airflow Limitation

Back 14

Patients with COPD typically show a decrease in both FEV1 and FVC

Postbronchodilator FEV1 <80% predicted + FEV1/FVC <70% confirms the presence of airflow limitation that is not fully reversible

FEV1/FVC <70% is an early sign of airflow limitation in patients whose FEV1 remains normal (>80% predicted).

Front 15

Assess: Additional Investigations > Stage II: Moderate COPD

Back 15

Bronchodilator reversibility testing
-rule out asthma
-establish best attainable lung function
-gauge a patient's prognosis
-guide treatment decisions
Chest x-ray
-valuable in excluding alternative diagnoses

Front 16

Assess: Additional Investigations > Stage II: Moderate COPD

Arterial blood gas measurement

Back 16

--In advanced COPD: FEV1 <40% predicted or signs suggestive of respiratory failure or right heart failure
--central cyanosis, ankle swelling, Jugular Venous Distention
--Respiratory failure
PaO2 < 60 mm Hg +/- PaCO2 >50 mm Hg

Front 17

Assess: Additional Investigations > Stage II: Moderate COPD

Alpha-1 antitrypsin deficiency screening

Back 17

COPD at a young age-emphysema
strong family history of the disease

Front 18

Elastase is major player
Breaks down elastin (emphysema)
Antiprotease that prevents the activity of the elastase

Back 18

true

Front 19

Differential Diagnosis

Back 19

A major differential diagnosis is asthma
In some patients with chronic asthma, a clear distinction from COPD is not possible
In these cases, current management is similar to that of asthma
Other potential diagnoses are usually easier to distinguish from COPD

Front 20

COPD

Back 20

Onset in mid-life
Symptoms slowly progressive
Long smoking history
Dyspnea during exercise
Largely irreversible airflow limitation

Front 21

Asthma

Back 21

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

Front 22

Congestive Heart Failure

Back 22

Fine basilar crackles on auscultation
Chest x-ray shows dilated heart, pulmonary edema
PFTs indicate restriction- not obstruction
B-type Natriuretic Peptide BNP

Front 23

Monitoring: This is a progressive disease

Back 23

--Lung function worsens over time- even with best care
--Monitor symptoms and objective measures of airflow limitation to determine when to adjust therapy
--Spirometry should be performed if there is a substantial increase in symptoms or a complication
--ABG should be considered in all patients with an FEV1 <40% predicted or clinical signs of respiratory failure or right heart failure (JVD/edema)

Front 24

reduce risk factors

Back 24

--Reducing exposure to tobacco smoke, occupational dusts, and chemicals, and indoor and outdoor air pollutants
--Smoking cessation is the single most effective -- and cost-effective -- intervention to reduce the risk of developing COPD and stop its progression

Front 25

Reduce Risk Factors: Key Points

Back 25

Brief tobacco dependence treatment is

Every tobacco user should be offered at this treatment at every visit

Front 26

reduce risk factors
(pharmacological...)

Back 26

There are effective pharmacotherapies for tobacco dependence
Add meds to counseling if necessary
Progression of many occupationally induced respiratory disorders can be reduced or controlled by reducing inhaled particles and gases

Front 27

manage stable COPD

Back 27

All COPD patients benefit from exercise training program
Improves both exercise tolerance and symptoms of dyspnea and fatigue

Front 28

Chronic Obstructive Pulmonary Disease: (COPD)

Back 28

COPD is characterized by airway obstruction, chronic inflammation that is not completely reversible.
Two primary diseases are chronic bronchitis and emphysema.
Bronchitis is classified as chronic when patient coughs up sputum most of the days of a three-month period, two consecutive years in a row.
“Asthma” has similar symptoms but is reversible; control the acute event as much as possible avoiding COPD.

Front 29

Bronchodilators: Beta2-agonists

Increase cAMP in smooth muscle

Back 29

Activates Protein Kinase A
Inhibits activity of myosin light chain kinase
Inhibiting smooth muscle contraction

Front 30

Bronchodilators: Beta2-agonists

Short-acting

Back 30

Fenoterol
Salbutamol (albuterol)
Terbutaline

Front 31

Bronchodilators: Beta2-agonists

long acting

Back 31

Formoterol
Salmeterol

Front 32

Bronchodilators: Anticholinergics

mode of action

Back 32

Cholinergic tone is only reversible component of COPD
Normal airway have small degree of vagal cholinergic tone
Block muscarinic receptors
Prevent
Induce smooth muscle relaxation

Front 33

Bronchodilators: Anticholinergics

Short acting

Back 33

Ipratropium bromide
Oxitropium bromide

Front 34

Bronchodilators: Anticholinergics

long acting

Back 34

Tiotropium

Front 35

Bronchodilators- Combos and Methylxanthines

Combination beta2-agonists plus anticholinergic in one inhaler

Back 35

Fenoterol/Ipratropium
Salbutamol/Ipratropium

Front 36

Bronchodilators- Combos and Methylxanthines

Methylxanthines

Back 36

Aminophylline (slow release preparations)
Theophylline (slow release preparations)
RARELY OF SIGNIFICNAT BENEFIT

Front 37

Leukotrienes

Back 37

--LTs are released from mostly from mast cells, basophils and eosinophils
--Other cell types release LTs such as:
Epidermal cells
Macrophages
Neutrophils
--LTs causes
Activation of neutrophils and monocytes
Eosinophil migration
Leukocyte adhesion
Increased capillary permeability
Smooth muscle contraction

Front 38

Other Med Adjuncts

Back 38

--Influenza vaccines significantly reduce serious illness and death
--Pneumococcal vaccine –OK to use but data lacking
--Antibiotics: other than treating infectious exacerbations- not recommended (Evidence A)
--Mucolytic Agents: a few patients with viscous sputum may benefit but the widespread use cannot be recommended
--Antitussives: Cough, a troublesome symptom in COPD, has a protective role. Regular use of antitussives contraindicated
--Narcotics: The use of opioids effective for dyspnea in advanced disease