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Chronic Obstructive Pulmonary Disease. Copd
By Dr. D.S. Merchant

Plan of Attack
•Definitions
•Epidemiology
•Goals of Management
•Diagnosis
•Managing Stable COPD
•Managing Acute Exacerbations of COPD

“A disease state characterized by airflow limitation that is not fully reversible. Airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Symptoms, functional abnormalities, and complications of can all be explained on the basis of this underlying inflammation and the resulting pathology.”
Definitions
•Chronic Bronchitis (clinical)
•Sputum production more days than not for at least 3 months a year for at least 2 years
•Emphysema (pathologic)
•Parenchymal destruction airspace walls distal to terminal bronchioles, without fibrosis
•Important: You can have either, but to have you MUST demonstrate obstruction (thus the “O” in COPD)

Epidemiology
•Fourth leading cause of death in U.S.
•100,000 American deaths each year
•15-20% of chronic smokers develop COPD
•2.5% mortality for hospital admissions
•COPD with acute respiratory failure:
•24% in hospital mortality
•59% one year mortality
•If you have and PaCO2 > 50mmHg:
•67% chance of being alive in 6 months
•57% chance of being alive in 12 months

Diagnosis
•Symptoms
•Dyspnea
•Sputum production (especially in the morning)
•Recurrent acute chest illnesses
•Headache in the morning – possible hypercapnia
•Cor pulmonale (Right heart failure)

Goals Of Management
•Identifying and ameliorating (if possible) the cause of the acute exacerbation
•Optimizing lung function by administering bronchodilators and other pharmacotherapy
•Assuring adequate oxygenation and secretion clearance
•Averting the need for intubation, if possible
•Preventing complications of immobility, such as thromboemboli and deconditioning
•Addressing nutritional needs – at the time of the acute illness, most patients are in negative nitrogen balance, which is exacerbated by steroid therapy

Diagnosis:
•Signs
•Prolonged expiratory time
•Expiratory wheezes
•Increased AP diameter of chest
•Decreased breath sounds (especially upper lung fields)
•Distant heart sounds
•End stage: accessory muscles, pursed lip breathing, cyanosis, enlarged liver and pedal edema (in case of cor pulmonale).

Diagnosis
•Radiology
•Chest X-ray
•Hyperinflated lung fields more radiolucent
•Bullae, often bilateral upper lobes in smokers
•Flat diaphragms (best seen on lateral) and retrosternal airspace can indicate air trapping
•High Resolution CT of Chest
•Most sensitive to detect above changes
•No role in routine care of patients
•Can be useful for giant bullous disease surgeries or lung volume reduction surgery planning

Diagnosis
•Pulmonary Function Testing
•Spirometry: Decreased FEV1/FVC
•FEV1 percent predicted defines severity
•Lung volumes: Increased TLC, RV, RV/TLC
•DLCO: Decreased

Gold Staging Criteria
•Stage O: Normal spirometry; chronic sx
•Stage 1 (Mild):
•FEV1/FVC < 70%; FEV1 > 80% predicted
•Stage 2 (Moderate):
•FEV1/FVC < 70%; FEV1 30-80% predicted
•2A: FEV1 50-80% predicted
•2B: FEV1 30-50% predicted

Diagnosis
•Stage 3 (severe):
•FEV1/FVC < 70% AND:
•FEV1 < 30% predicted OR:
•FEV1 < 50% predicted and clinical evidence of Right heart failure

Diagnosis
American Thoracic Society – Spirometry
•Low FEV1/FVC defines obstruction
•FEV1%predicted Category
•< 35% Very Severe
•35-50% Severe
•50-60% Moderately Severe
•60-70% Moderate
•70-80% Mild
•80-100% Mild vs. Normal variant
•> 100% Normal

Managing Stable COPD
•Smoking Cessation Is KEY!
•YOUR intervention will make a difference – must address at each visit
•Medication
•Two therapies ONLY have been shown to improve mortality in stable COPD:
•1) Smoking Cessation
•2) Oxygen Therapy

Bronchodilator Technique
•MDI’s get better drug deposition than nebs
•Use a spacer device with MDI’s
•Technique is key – important for patient and doctor
•Inadequate dosing can hamper treatment

•Sympathomimetics
•Beta-2 selectivity is good
•Some additive vs. slightly synergistic effects of combining beta-2 agonist and ipratropium (Combivent)
•Some data to support decreased H.influenzae pneumonia incidence with Serevent
Anticholinergic Agents (Atrovent, glycopyrrolate)
•Similar ability to bronchodilate (in appropriate doses) as beta-agonists
•Also reduces sputum volume; no change in viscosity
•Usually under dosed
•Recommend 2 (36 mcg) puffs qid
•glycopyrrolate which is manufactured for IV/IM use for other indications, is available only "off label" for nebulized use in (1 to 2 mg every two to four hours).
•Aminophylline and theophylline are not recommended for the management of acute exacerbations of COPD. Randomized controlled trials of intravenous aminophylline in this setting have failed to show efficacy in excess of that afforded by therapy with inhaled bronchodilators and corticosteroids

Mucokinetic agents
•There is little evidence supporting the use of mucokinetic (mucolytic) agents, such as N-acetylcysteine or iodide preparations, in acute exacerbations of COPD. In fact, some drugs of this class may worsen bronchospasm.

•Oxygen. Yes.
•Demonstrated to improve exercise performance, symptom indices and mortality
•Goal

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Asparagus urine and other strange food reactions
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University of Maryland discovery may lead to 'smart pill'
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in hypercapnic patients for SpO2 need not be greater than 88-90%
•Always test patients for oxygenation with ambulation if baseline at rest room air SpO2 ok

•Systemic Corticosteroids
•Never demonstrated to significantly impact mortality or exercise capacity
•Slight improvements in symptom indices
•Significant side effects
•Rarely of benefit, generally of harm to your patient
•Occasionally useful in a small subset failing other therapies AND with demonstrated bronchodilator response on PFT’s

•Inhaled Corticosteroids
•Jury still out
•Lots of recent research with some favorable data supporting its use
•May be part of standard regimens in the future

•Vaccines
•Pneumovax, annual flu shots
•Chronic antibiotic therapy – BAD IDEA
•Nutritional status – Important
•Pulmonary Rehabilitation
•Improved exercise capacity, symptom scores
•Lung Volume Reduction Surgery
•Transplant

Managing Acute Exacerbations of COPD
•Common precipitants:
•Infection – esp viral or bacterial
•Acute bronchospasm
•Sedation

•Who To Admit•
•Countless studies, few definite answers
•Worsening hypoxemia and/or hypercapnia
•Otherwise, mostly a clinical decision
•Key points to consider:
•Oxygen
•Bronchodilators
•Steroids
•Antibiotics

•Albuterol:
•Neb or MDI – neb MAY be better in acute setting, but MDI’s have better drug deposition overall
•Continuous nebulizer treatments confer no benefit over treatments every 1-2 hours
•Generally should avoid subcutaneous beta-agonists
•BEWARE: Hypokalemia, tachycardia (occasional)
•Levalbuterol still with weak clinical data – few situations where it is clinically indicated

•ATROVENT (anticholinergic bronchodilator)
•Bronchodilation
•May decrease secretions
•Few significant side effects
•Usually significantly under dosed – emerging data supports much higher doses than usually used currently

•Corticosteroids — Parenteral corticosteroids are frequently used in treating acute exacerbations of COPD. Methylprednisolone (60 to 125 mg intravenously, two to four times daily) or the equivalent glucocorticoid dose of other steroid preparations commonly is given.
•Corticosteroids Utilization in this setting was initially based upon small randomized trials in which only a minority of patients benefit and the degree of improvement is modest
•A randomized, placebo-controlled trial of 271 patients has confirmed the benefits of systemic corticosteroids given for up to 2 weeks to hospitalized patients with exacerbation

•Antibiotics
•“Winnipeg” Criteria (give for 2-3 of the following):
•Increased cough
•Increased purulence
•Increased sputum production
•Antibiotics accelerate improvement in peak expiratory flow rates and lessen the rate of recrudescence in this setting
•Amoxicillin, Doxycycline, TMP/SMX, Azithromycin, Clarithromycin, Levaquin for 10 days

•Mucokinetic Agents – JUST SAY NO.
•N-acetylcysteine is actually contraindicated in patients with airway obstruction
•No significant clinical benefit ever demonstrated
•Chest PT, intermittent positive pressure breathing and postural drainage may actually be harmful in the setting of acute obstruction

•Methylxanthines (Theophylline, Aminophylline)
•Not recommended for acute exacerbations
•No significant benefit ever demonstrated in large, prospective trials

•Oxygen: YES!
•Generally a good thing – cells like that stuff
•If requiring a significant increase in FiO2 over baseline requirement, start hunting for something other than just exacerbation
•BEWARE of CO2 RETAINERS! (goal SpO2 90%, PaO2 of 60 to 65 mmHg )
•1) Altered V/Q relationships
•2) Haldane effect (Hgb*O2 holds less CO2 – goes out into plasma)
•3) Decreased ventilatory drive (least impt mechanism)

•Non-Invasive Positive Pressure Ventilation
•BiPAP
•Set FiO2, inspiratory (IPAP) and expiratory (EPAP)
•Difference between IPAP and EPAP augments tidal volume, therefore improving minute ventilation. CO2 then gets blown off
•MORTALITY BENEFIT in patients who will tolerate

•Mechanical Ventilation
•Respiratory distress
•Acidemia that does not correct quickly with therapy
•Inability to oxygenate adequately
•Often a clinical decision relative to patient’s work of breathing

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Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Resident AKUH, Pakistan. For more information on Gastroenterology or visit www.ezinevalley.com is a popular website that offers information on Endoscopy, Pulmonary Disease and VHF Medications.

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The plaques are clumps of a small protein called beta-amyloid that build up in the space around nerve cells and interfere with normal brain function. Thus, the thinking goes, if plaques can be prevented from forming or cleared with medicine, the disease could be slowed. <p><a href="http://feedads.g.doubleclick.net/~at/wRimKi684jDxBA7DCC3i21QsLOA/0/da"><img src="http://feedads.g.doubleclick.net/~at/wRimKi684jDxBA7DCC3i21QsLOA/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/wRimKi684jDxBA7DCC3i21QsLOA/1/da"><img src="http://feedads.g.doubleclick.net/~at/wRimKi684jDxBA7DCC3i21QsLOA/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/h7KTuepA11Q" height="1" width="1"/> Alzheimer's Assn. Graduation Club copes together The program allows diagnosed patients to socialize with others who understand. <br/><br/> Leaning forward in his chair, Bob Patterson, 64, addresses a small group of his peers seated around a conference table. "You want to fill each day with something that's relevant," he says. "Live like it's the last day of your life, whether you have a disease or not." <p><a href="http://feedads.g.doubleclick.net/~at/NF6AbbzHru9l17GiQMpVoELNU_Y/0/da"><img src="http://feedads.g.doubleclick.net/~at/NF6AbbzHru9l17GiQMpVoELNU_Y/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/NF6AbbzHru9l17GiQMpVoELNU_Y/1/da"><img src="http://feedads.g.doubleclick.net/~at/NF6AbbzHru9l17GiQMpVoELNU_Y/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/skrV7g3kcrk" height="1" width="1"/> Help for Alzheimer's caregivers Government and private organizations can aid those taking care of a loved one or seeking a facility. <br/><br/> If you're caring for a loved one with Alzheimer's, you're in plenty of company. Nearly 11 million people take care of the 5.3 million Americans with the disease, a number that's expected to grow to almost 16 million by 2050, according to the Alzheimer's Assn. <p><a href="http://feedads.g.doubleclick.net/~at/E95ixDhe1_KLb3yIUTz2biBpv4A/0/da"><img src="http://feedads.g.doubleclick.net/~at/E95ixDhe1_KLb3yIUTz2biBpv4A/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/E95ixDhe1_KLb3yIUTz2biBpv4A/1/da"><img src="http://feedads.g.doubleclick.net/~at/E95ixDhe1_KLb3yIUTz2biBpv4A/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/WNFwbh1R77Q" height="1" width="1"/> Prescription drugs for Alzheimer's disease Five medications have been approved to treat the cognitive symptoms of Alzheimer's disease. The drugs can reduce some symptoms — such as difficulties with memory, language, attention and reasoning — especially in the early stages of the disease. They can, accordingly, improve quality of life, but they don't work for everyone, and none of them works permanently. Eventually the disease will overtake the drugs' ability to compensate. <p><a href="http://feedads.g.doubleclick.net/~at/P7zseKU9WJKptKTi02rXI1r2CEo/0/da"><img src="http://feedads.g.doubleclick.net/~at/P7zseKU9WJKptKTi02rXI1r2CEo/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/P7zseKU9WJKptKTi02rXI1r2CEo/1/da"><img src="http://feedads.g.doubleclick.net/~at/P7zseKU9WJKptKTi02rXI1r2CEo/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/tuD9i6WAOqk" height="1" width="1"/> Sniffing device may help the severely disabled communicate For those unable to move or speak, a new mechanism using nasal breath control is shown to help them write and guide a wheelchair. A patent is being pursued. <br/><br/> The severely disabled, including those "locked in" to their bodies as a result of accidents or disease, may soon have a new way to communicate and move around, Israeli scientists said Monday. <p><a href="http://feedads.g.doubleclick.net/~at/48gRux6IU_kJ4k13Q3Ue1nAaqN4/0/da"><img src="http://feedads.g.doubleclick.net/~at/48gRux6IU_kJ4k13Q3Ue1nAaqN4/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/48gRux6IU_kJ4k13Q3Ue1nAaqN4/1/da"><img src="http://feedads.g.doubleclick.net/~at/48gRux6IU_kJ4k13Q3Ue1nAaqN4/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/hJv9eWvakPs" height="1" width="1"/> Effect of call-based counseling ringing true Hospitals and clinics have been showing success with therapy by phone. One study even finds it can help cancer patients. <br/><br/> The therapist-patient relationship is crucial to people battling depression, addiction, weight gain and diabetes. But that relationship might not always have to be in person to be effective. <p><a href="http://feedads.g.doubleclick.net/~at/2Wg0Alg9qyHKsqzy3dSgZaAu6mM/0/da"><img src="http://feedads.g.doubleclick.net/~at/2Wg0Alg9qyHKsqzy3dSgZaAu6mM/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/2Wg0Alg9qyHKsqzy3dSgZaAu6mM/1/da"><img src="http://feedads.g.doubleclick.net/~at/2Wg0Alg9qyHKsqzy3dSgZaAu6mM/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/gYCPbPKhEcQ" height="1" width="1"/> Pantry Raid: Vegan doesn't necessarily mean healthy They try to avoid animal products. But that doesn't mean the busy couple won't run to a fast-food outlet or snack on potato chips when pressed. <br/><br/> Every so often, we take a candid look at the private dietary lives of people whose food choices need a makeover. Up this week: the kitchen and dining habits of 22-year-old Jessica Watson and her boyfriend, 31-year-old Todd Preboski. <p><a href="http://feedads.g.doubleclick.net/~at/s2k8XXRnJ739C6FUs2hMeuk0qpo/0/da"><img src="http://feedads.g.doubleclick.net/~at/s2k8XXRnJ739C6FUs2hMeuk0qpo/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/s2k8XXRnJ739C6FUs2hMeuk0qpo/1/da"><img src="http://feedads.g.doubleclick.net/~at/s2k8XXRnJ739C6FUs2hMeuk0qpo/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/5UPxCCihjC0" height="1" width="1"/> Pantry Raid: Taken to task in May, a publicist gives up fast food and now makes most of her own meals Stephanie Jacobson has cut down on sodium, doesn't miss the greasy burgers and fries, and has taken up running. <br/><br/> In May, we raided the nutritionally bankrupt pantry of Stephanie Jacobson, a Toluca Lake publicist whose meals were based on processed and frozen foods — or fast food. She was so hard-core she had Chipotle and Pizza Hut apps on her phone. <p><a href="http://feedads.g.doubleclick.net/~at/F7KbAtfYdfGBUYjHjQJ9lvJcoHg/0/da"><img src="http://feedads.g.doubleclick.net/~at/F7KbAtfYdfGBUYjHjQJ9lvJcoHg/0/di" border="0" ismap="true"></img></a><br/> <a href="http://feedads.g.doubleclick.net/~at/F7KbAtfYdfGBUYjHjQJ9lvJcoHg/1/da"><img src="http://feedads.g.doubleclick.net/~at/F7KbAtfYdfGBUYjHjQJ9lvJcoHg/1/di" border="0" ismap="true"></img></a></p><img src="http://feeds.feedburner.com/~r/latimes/features/health/~4/gOJcbjBXGUg" height="1" width="1"/>

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