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1 COPD M3 lecture Tammy Wichman MD Assistant Professor of Medicine Pulmonary-Critical Care

2 A 55 year old male presents to the office with worsening shortness of breath over the past 6 months. He has a morning cough productive of thick white sputum. He denies any chest pain. His weight has been stable. He has a 45 pack year smoking history and continues to smoke ½ pack per day. He drinks several beers on the weekends. He is divorced and works as an engineer. What of the following tests should you order to work up his dyspnea?A 55 year old male presents to the office with worsening shortness of breath over the past 6 months. He has a morning cough productive of thick white sputum. He denies any chest pain. His weight has been stable. He has a 45 pack year smoking history and continues to smoke ½ pack per day. He drinks several beers on the weekends. He is divorced and works as an engineer. What of the following tests should you order to work up his dyspnea? Pulmonary Function Tests including DLCOPulmonary Function Tests including DLCO Chest x-rayChest x-ray Spiral CT to rule out chronic thromboembolic diseaseSpiral CT to rule out chronic thromboembolic disease High-resolution CT to evaluate for interstitial fibrosisHigh-resolution CT to evaluate for interstitial fibrosis Methacholine challengeMethacholine challenge Allergy Skin TestingAllergy Skin Testing Pre- and Post-Bronchodilator spirometryPre- and Post-Bronchodilator spirometry Arterial blood gasArterial blood gas 6 minute walk6 minute walk

3 SYMPTOMS cough sputum dyspnea EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY Diagnosis of COPD è è

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5 Spirometry

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7 The severity of disease in COPD is assessed by _________. The classification system is called ________.The severity of disease in COPD is assessed by _________. The classification system is called ________. Disease severity ________ (is or is NOT) associated with mortality.Disease severity ________ (is or is NOT) associated with mortality.

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9 Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697 Deterioration in Lung Function in Patients with COPD

10 Celli, B. R. et al. N Engl J Med 2004;350:1005-1012 Variables and Point Values Used for the Computation of the Body-Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity (BODE) Index

11 Celli, B. R. et al. N Engl J Med 2004;350:1005-1012 Kaplan-Meier Survival Curves for the Four Quartiles of the Body-Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity Index (Panel A) and the Three Stages of Severity of Chronic Obstructive Pulmonary Disease as Defined by the American Thoracic Society (Panel B)

12 Other tests Bronchodilator reversibilityBronchodilator reversibility –Helpful to rule out a diagnosis of asthma, to establish a patient’s best attainable lung function, to gauge a patient’s prognosis, and to guide treatment decisions –Even patients who do not show a significant FEV 1 response to a short- acting bronchodilator test may benefit symptomatically CXR-seldom diagnostic unless obvious bullous disease is present but it is valuable in excluding alternative diagnosisCXR-seldom diagnostic unless obvious bullous disease is present but it is valuable in excluding alternative diagnosis ABG-should be measured in patients with FEV 1 <40% predicted or with cor pulmonaleABG-should be measured in patients with FEV 1 <40% predicted or with cor pulmonale Alpha-1 antitrypsin deficiency: in patients who develop COPD at a young age or who have a family historyAlpha-1 antitrypsin deficiency: in patients who develop COPD at a young age or who have a family history

13 COPD Definition Fill in the blanks Disease state characterized by ____________ that is not fully __________. The _______________ is usually both progressive and associated with an abnormal inflammatory response of the lungs to _______________.Disease state characterized by ____________ that is not fully __________. The _______________ is usually both progressive and associated with an abnormal inflammatory response of the lungs to _______________.

14 COPD Definition Disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.Disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease www.goldcopd.comGlobal Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease www.goldcopd.com

15 Lancet 2003;362:1053-61

16 Pathology of COPD Fill in the boxes SMOKINGPathologyPhysiologicConsequence Large airways 1.2.1. Small airways 1.2.3.1. Alveoli1.1.

17 Pathology

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20 What is the single most effective intervention to stop the progression of COPD in this patient?What is the single most effective intervention to stop the progression of COPD in this patient? How would you do this? Be specific.How would you do this? Be specific.

21 Smoking Cessation Single most effective (and cost effective) intervention to reduce the risk of developing COPD and stop its progressionSingle most effective (and cost effective) intervention to reduce the risk of developing COPD and stop its progression Brief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to the health care providerBrief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to the health care provider

22 Strategies to Help the Patient Willing to Quit Smoking 1. ASK: Systematically identify all tobacco users at every visit.1. ASK: Systematically identify all tobacco users at every visit. 2. ADVISE: Strongly urge all tobacco users to quit.2. ADVISE: Strongly urge all tobacco users to quit. 3. ASSESS: Determine willingness to make a quit attempt.3. ASSESS: Determine willingness to make a quit attempt. 4. ASSIST: Aid the patient in quitting4. ASSIST: Aid the patient in quitting 5. ARRANGE: Schedule follow-up contact5. ARRANGE: Schedule follow-up contact

23 Pharmacotherapy Nicotine replacement reliably increases long- term smoking abstinence ratesNicotine replacement reliably increases long- term smoking abstinence rates Bupropion and Nortriptyline have been shown to increase long-term quit ratesBupropion and Nortriptyline have been shown to increase long-term quit rates

24 Effects of Smoking Cessation on Natural History of FEV 1 Fletcher C, Peto R. Br Med J. 1977;1:1645-1648. Smoked Regularly and Susceptible to Its Effects Stopped at Age 45 Years Stopped at Age 65 Years Never Smoked or not Susceptible to Smoke FEV 1 (Percentage of Value at Age 25 Years) Age (Years) 25 5075 †† 0 25 50 75 100 Disability Death

25 Anthonisen et al. Smoking and lung function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med 2002;166(5)675-9.

26 Anthonisen et al. Lung Health Study Research Group. Ann Intern Med 2005;142:233-9

27 Mortality benefit despite the fact that only 21.7% of smoking intervention group quit vs 5.4% of usual care group

28 A 61 year old female presents to the office with worsening shortness of breath. Symptoms have been gradually worsening over the past several years. She has a chronic cough productive of white sputum. Patient was started on oxygen by her primary care physician last month and was referred to you for further evaluation. Her past medical history is significant for hypertension. She quit smoking several years ago. She drinks one glass of wine a day. She recently quit her job as a day care provider. She denies any fever or chills. Her current medications are:A 61 year old female presents to the office with worsening shortness of breath. Symptoms have been gradually worsening over the past several years. She has a chronic cough productive of white sputum. Patient was started on oxygen by her primary care physician last month and was referred to you for further evaluation. Her past medical history is significant for hypertension. She quit smoking several years ago. She drinks one glass of wine a day. She recently quit her job as a day care provider. She denies any fever or chills. Her current medications are: VoSpire (Albuterol) ER 8 mg po Q 12 hoursVoSpire (Albuterol) ER 8 mg po Q 12 hours Atrovent nebulizers Q 6 hoursAtrovent nebulizers Q 6 hours Prednisone 10mg po Q dayPrednisone 10mg po Q day Theophylline 200mg po BIDTheophylline 200mg po BID Inderal (Propranolol) 80 mg po BIDInderal (Propranolol) 80 mg po BID

29 On exam, T 37.5 HR 82 R 16 BP 135/65 Sats 95% on 2L O2 by nasal cannula. She has a mildly increased P2 on cardiac exam. She has a prolonged expiratory phase on lung exam with scattered end-expiratory wheezes. The rest of her exam is normal. Her CXR is available for review. Her pulmonary function tests are: FVC 1.56 L 59% predicted improving to 1.9 L 72% predicted, a 22% improvement. FEV1 0.67 36% predicted improving to 0.92 L a 37% improvement. TLC 120% predicted. RV 191% predicted and DLCO 38% predicted.On exam, T 37.5 HR 82 R 16 BP 135/65 Sats 95% on 2L O2 by nasal cannula. She has a mildly increased P2 on cardiac exam. She has a prolonged expiratory phase on lung exam with scattered end-expiratory wheezes. The rest of her exam is normal. Her CXR is available for review. Her pulmonary function tests are: FVC 1.56 L 59% predicted improving to 1.9 L 72% predicted, a 22% improvement. FEV1 0.67 36% predicted improving to 0.92 L a 37% improvement. TLC 120% predicted. RV 191% predicted and DLCO 38% predicted. How would you rate the severity of her disease?How would you rate the severity of her disease? What adjustments should be made to her medical regimen?What adjustments should be made to her medical regimen? Can anything be done to prolong her life?Can anything be done to prolong her life? Are there any non-medical options available to improve her condition?Are there any non-medical options available to improve her condition?

30 Which of the following are objectives of COPD management? Prevent disease progressionPrevent disease progression Improve pulmonary function testsImprove pulmonary function tests Relieve symptomsRelieve symptoms Repair emphysematous lungsRepair emphysematous lungs Improve exercise toleranceImprove exercise tolerance Improve health statusImprove health status Decrease oxygen requirementsDecrease oxygen requirements Prevent and treat exacerbationsPrevent and treat exacerbations Reduce mortalityReduce mortality Minimize side effects from treatmentMinimize side effects from treatment Prevent disease progressionPrevent disease progression Improve pulmonary function testsImprove pulmonary function tests Relieve symptomsRelieve symptoms Repair emphysematous lungsRepair emphysematous lungs Improve exercise toleranceImprove exercise tolerance Improve health statusImprove health status Decrease oxygen requirementsDecrease oxygen requirements Prevent and treat exacerbationsPrevent and treat exacerbations Reduce mortalityReduce mortality Minimize side effects from treatmentMinimize side effects from treatment

31 Objectives of COPD Management Prevent disease progressionPrevent disease progression Relieve symptomsRelieve symptoms Improve exercise toleranceImprove exercise tolerance Improve health statusImprove health status Prevent and treat exacerbationsPrevent and treat exacerbations Prevent and treat complicationsPrevent and treat complications Reduce mortalityReduce mortality Minimize side effects from treatmentMinimize side effects from treatment Prevent disease progressionPrevent disease progression Relieve symptomsRelieve symptoms Improve exercise toleranceImprove exercise tolerance Improve health statusImprove health status Prevent and treat exacerbationsPrevent and treat exacerbations Prevent and treat complicationsPrevent and treat complications Reduce mortalityReduce mortality Minimize side effects from treatmentMinimize side effects from treatment

32 Monitor Disease Progression COPD is a progressive disease, and a patient’s lung function can be expected to worsen over time, even with the best available careCOPD is a progressive disease, and a patient’s lung function can be expected to worsen over time, even with the best available care

33 Manage Stable COPD Stepwise increase in treatment, depending on the severity of the disease.Stepwise increase in treatment, depending on the severity of the disease. Patient education improves skills, ability to cope with illness and health status.Patient education improves skills, ability to cope with illness and health status. None of the existing medications for COPD has been shown to modify the long-term decline in lung function. So pharmacotherapy is used to decrease symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise toleranceNone of the existing medications for COPD has been shown to modify the long-term decline in lung function. So pharmacotherapy is used to decrease symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance

34 Manage Stable COPD: Bronchodilators Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms.Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. –Alleviate symptoms –Improve exercise tolerance –Improve quality of life –Decrease the incidence of exacerbations –Decrease hyperinflation Inhaled therapy is preferredInhaled therapy is preferred

35 Manage Stable COPD: Bronchodilators Beta 2 -agonists: increase cyclic adenosine monophosphate levels and promote airway smooth- muscle relaxationBeta 2 -agonists: increase cyclic adenosine monophosphate levels and promote airway smooth- muscle relaxation –Short acting: Albuterol (Proventil) –Long acting: Salmeterol (Serevent) and Formoterol fumarate (Foradil) Anticholinergics: block muscarinic receptorsAnticholinergics: block muscarinic receptors –Short acting: Ipratropium bromide (Atrovent) –Long acting: Tiotropium bromide (Spiriva) Combination: (Combivent, DuoNeb)Combination: (Combivent, DuoNeb)

36 Manage Stable COPD: Bronchodilators Phosphodiesterase Inhibitors: increase intracellular cyclic adenosine monophosphate levels within airway smooth musclePhosphodiesterase Inhibitors: increase intracellular cyclic adenosine monophosphate levels within airway smooth muscle –3 rd line agent –Improves respiratory muscle function, stimulates the respiratory center, decreases dyspnea, and enhances activities of daily living –Toxic side effects: tachyarrhythmias, nausea, vomiting, seizures –Monitoring should include intermittent serum level measurements: target range 8-12mcg/mL

37 Inhaled Steroids (ICS) in Stable COPD Glucocorticoids act at multiple points within the inflammatory cascade.Glucocorticoids act at multiple points within the inflammatory cascade. Regular treatment with ICS does not modify the long-term decline in FEV 1.Regular treatment with ICS does not modify the long-term decline in FEV 1. Appropriate for symptomatic COPD patients with an FEV 1 < 50% and repeated exacerbations (Stage III and IV).Appropriate for symptomatic COPD patients with an FEV 1 < 50% and repeated exacerbations (Stage III and IV). ICS reduce frequency of exacerbations and improve health status (Evidence A).ICS reduce frequency of exacerbations and improve health status (Evidence A). ICS combined with long-acting  2-agonist more effective than individual components.ICS combined with long-acting  2-agonist more effective than individual components.

38 Steroids in Stable COPD Steroids in Stable COPD GOLD guidelines recommend a trial of 6 weeks to 3 months of ICS to identify subset of patients who may benefit.GOLD guidelines recommend a trial of 6 weeks to 3 months of ICS to identify subset of patients who may benefit. Short course of oral steroids is a poor predictor of long-term response to ICS.Short course of oral steroids is a poor predictor of long-term response to ICS. Long-term treatment with oral steroids is NOT recommended (Evidence A):Long-term treatment with oral steroids is NOT recommended (Evidence A): –No evidence of long-term benefit –Major side effects: skin damage, cataracts, diabetes, osteoporosis, secondary infection, psychosis, fluid retention

39 Other pharmacologic treatments Vaccines: Influenza vaccine reduces serious illness and death in COPD patients by 50%. Pneumococcal vaccine is recommended every 5 years although data in COPD patients is lacking.Vaccines: Influenza vaccine reduces serious illness and death in COPD patients by 50%. Pneumococcal vaccine is recommended every 5 years although data in COPD patients is lacking. Other anti-inflammatory agents: Cromolyn, nedocromil, and leukotriene inhibitors have not been adequately tested in patients with COPDOther anti-inflammatory agents: Cromolyn, nedocromil, and leukotriene inhibitors have not been adequately tested in patients with COPD Alpha-1 Antitrypsin Augmentation Therapy: young patients with severe deficiency and established emphysemaAlpha-1 Antitrypsin Augmentation Therapy: young patients with severe deficiency and established emphysema Antibiotics are not recommended other than in treating infectious exacerbations (Doxycycline, amoxicillin, macrolide, fluoroquinolones)Antibiotics are not recommended other than in treating infectious exacerbations (Doxycycline, amoxicillin, macrolide, fluoroquinolones) Mucolytic agents: not recommendedMucolytic agents: not recommended Antioxidants (N-acetylcysteine) may reduce the frequency of exacerbationsAntioxidants (N-acetylcysteine) may reduce the frequency of exacerbations Antitussives: contraindicated in stable COPD because cough is protectiveAntitussives: contraindicated in stable COPD because cough is protective

40 Comprehensive pulmonary rehabilitation programs have been shown to improve all of the following EXCEPT:Comprehensive pulmonary rehabilitation programs have been shown to improve all of the following EXCEPT: A. Measured FEV1A. Measured FEV1 B. Respiratory symptomsB. Respiratory symptoms C. 6-Minute walk testC. 6-Minute walk test D. Need for outpatient care and inpatient hospitalizationsD. Need for outpatient care and inpatient hospitalizations E. Symptoms of anxiety, depression, and lack of well- beingE. Symptoms of anxiety, depression, and lack of well- being

41 Pulmonary Rehabilitation in Stable COPD All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A).All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A). The minimum length of an effective rehab program is 2 months; the longer the better (Evidence B).The minimum length of an effective rehab program is 2 months; the longer the better (Evidence B). Comprehensive pulmonary rehabilitation program includes exercise training, nutrition counseling, and education.Comprehensive pulmonary rehabilitation program includes exercise training, nutrition counseling, and education.

42 Manage Stable COPD: Oxygen The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure (Stage IV) has been shown to increase survival (Evidence A).The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure (Stage IV) has been shown to increase survival (Evidence A). Oxygen administration reduces hematocrit, pulmonary artery pressures, dyspnea, and rapid eye movement related hypoxemia during sleep.Oxygen administration reduces hematocrit, pulmonary artery pressures, dyspnea, and rapid eye movement related hypoxemia during sleep. Tailor prescription to patient: source, method of delivery, duration of use, flow rate at rest, during exercise, and sleepTailor prescription to patient: source, method of delivery, duration of use, flow rate at rest, during exercise, and sleep

43 Lancet 2003;362:1053-61

44 A 59 year old male presents with worsening shortness of breath. He was diagnosed with COPD several years ago and was told to wear oxygen at home. However, he doesn’t feel like he needs it. He continues to exercise for several minutes a day on the treadmill and does pull- ups. In the office, his O2 sats are 83% on room air so he is admitted to the hospital. T 98.9 HR 103 R 24 BP 142/82 Sats 91% on 6 L oxymizer. His weight is 144 lbs at 68 inches. He has temporal wasting. He has supraclavicular fullness, jugular venous distension to the jaw, a prominent P2 on cardiac exam. He has poor air movement throughout both lung fields.A 59 year old male presents with worsening shortness of breath. He was diagnosed with COPD several years ago and was told to wear oxygen at home. However, he doesn’t feel like he needs it. He continues to exercise for several minutes a day on the treadmill and does pull- ups. In the office, his O2 sats are 83% on room air so he is admitted to the hospital. T 98.9 HR 103 R 24 BP 142/82 Sats 91% on 6 L oxymizer. His weight is 144 lbs at 68 inches. He has temporal wasting. He has supraclavicular fullness, jugular venous distension to the jaw, a prominent P2 on cardiac exam. He has poor air movement throughout both lung fields.

45 Pulmonary function tests: FEV1/FVC 28.6% FEV1 0.51 L 18% predicted; FVC 1.8L 52% predicted. With albuterol, his FVC increases to 2.07 L, a 14% improvement. His TLC is 151% predicted. His RV is 359% predicted.Pulmonary function tests: FEV1/FVC 28.6% FEV1 0.51 L 18% predicted; FVC 1.8L 52% predicted. With albuterol, his FVC increases to 2.07 L, a 14% improvement. His TLC is 151% predicted. His RV is 359% predicted.

46 How would you rate his severity of disease?How would you rate his severity of disease? How should this patient be treated?How should this patient be treated? What (if any) bronchodilators would you use?What (if any) bronchodilators would you use? Is there any role for inhaled corticosteroids?Is there any role for inhaled corticosteroids? What about systemic corticosteroids?What about systemic corticosteroids? Any other beneficial interventions?Any other beneficial interventions?

47 True or False COPD is a disease process limited to the lungs. _______COPD is a disease process limited to the lungs. _______ COPD is the only disease in which mortality rates have been rising over the past several decades. _________COPD is the only disease in which mortality rates have been rising over the past several decades. _________

48 COPD is a systemic disease Systemic inflammationSystemic inflammation Skeletal muscle dysfunctionSkeletal muscle dysfunction Nutritional problemsNutritional problems High prevalence of depression and anxietyHigh prevalence of depression and anxiety –PRIME-MD: 1334 VA patients with COPD: 80% screened positive for depression or anxiety –Nicotine helps mitigate these symptoms

49 Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 0 0 0.5 1.0 1.5 2.0 2.5 3.0 Proportion of 1965 Rate 1965 - 1998 –59% –64% –35% +163% –7% Coronary Heart Disease Coronary Heart Disease Stroke Other CVD COPD All Other Causes All Other Causes

50 Copyright restrictions may apply. Jemal, A. et al. JAMA 2005;294:1255-1259. Trends in Age-Standardized Death Rates for the 6 Leading Causes of Death in the United States, 1970-2002

51 COPD is the ___ leading cause of death in the United States.COPD is the ___ leading cause of death in the United States. A. 2ndA. 2nd B. 4thB. 4th C. 6thC. 6th D. 10thD. 10th

52 Epidemiology 4 th leading cause of death in the USA4 th leading cause of death in the USA In 2000, WHO estimates 2.74 million deaths worldwide from COPDIn 2000, WHO estimates 2.74 million deaths worldwide from COPD –In 2000, more women than men died of COPD in U.S. (59,936 vs 59,118) Age-adjusted death rates are risingAge-adjusted death rates are rising High burden of diseaseHigh burden of disease –Approx. 16 million office visits (USA, 1995) –500,000 hospitalizations for COPD –Medical expenditures ~ 15 billion dollars/yr; –$32 billion in direct and indirect costs in 2002

53 Management Stage 0: At Risk for COPD Characteristics Recommended Treatment Chronic symptoms - cough - sputum No spirometric abnormalities Avoidance of risk factors: Smoking cessation Influenza vaccination

54 Management Stage I: Mild COPD Characteristics Recommended Treatment FEV 1 /FVC < 70 % FEV 1 > 80 % predicted With or without symptoms Add Short-acting bronchodilator as needed

55 Management of Stage II: Moderate COPD Characteristics Recommended Treatment FEV 1 /FVC < 70% 50% < FEV 1 < 80% predicted With or without symptoms Add regular tx with long-acting BD Pulmonary rehab

56 Management of Stage III: Severe COPD Characteristics Recommended Treatment FEV 1 /FVC < 70% 30% < FEV 1 < 50% predicted With or without symptoms Add ICS if repeated exacerbations

57 Management of Stage IV: Very Severe COPD Characteristics Recommended Treatment FEV 1 /FVC < 70% FEV 1 < 30% predicted or presence of respiratory failure or right heart failure Long-term oxygen therapy Treatment of complications Consider surgical options

58 Lancet 2003;362:1053-61

59 Surgical Treatments Bullectomy: In carefully selected patients, this procedure is effective in reducing dyspnea and improving lung function (Evidence C)Bullectomy: In carefully selected patients, this procedure is effective in reducing dyspnea and improving lung function (Evidence C) Lung Volume Reduction SurgeryLung Volume Reduction Surgery Lung Transplantation: In appropriately selected patients, improves quality of life and functional capacity (Evidence C). Criteria for referral: FEV 1 50 mm Hg, and secondary pulmonary hypertensionLung Transplantation: In appropriately selected patients, improves quality of life and functional capacity (Evidence C). Criteria for referral: FEV 1 50 mm Hg, and secondary pulmonary hypertension

60 Lung Volume Reduction Surgery National Emphysema Treatment Trial Research GroupNational Emphysema Treatment Trial Research Group 1218 patients with severe emphysema underwent pulmonary rehabilitation and were randomly assigned to undergo lung- volume reduction surgery or to receive continued medical treatment1218 patients with severe emphysema underwent pulmonary rehabilitation and were randomly assigned to undergo lung- volume reduction surgery or to receive continued medical treatment Increases chance of improved exercise capacity but does not confer a survival advantageIncreases chance of improved exercise capacity but does not confer a survival advantage Survival advantage for patients with predominantly upper-lobe emphysema and low base-line exercise capacitySurvival advantage for patients with predominantly upper-lobe emphysema and low base-line exercise capacity

61 A 70 year old male with GOLD stage III COPD has had increased shortness of breath, chest tightness, and a cough productive of yellow sputum. In the ER, T 98.9 HR 115 R 32 BP 120/80 Sats 89% on 2 L O2 (his home O2 requirement). He is using accessory muscles (sternocleidomastoids) and has thoracoabdominal dyssynchrony. He has very poor air movement bilaterally on lung exam. The rest of his exam is unremarkable.A 70 year old male with GOLD stage III COPD has had increased shortness of breath, chest tightness, and a cough productive of yellow sputum. In the ER, T 98.9 HR 115 R 32 BP 120/80 Sats 89% on 2 L O2 (his home O2 requirement). He is using accessory muscles (sternocleidomastoids) and has thoracoabdominal dyssynchrony. He has very poor air movement bilaterally on lung exam. The rest of his exam is unremarkable.

62 How severe is his exacerbation?How severe is his exacerbation? What lab tests/x-rays should you order?What lab tests/x-rays should you order? How should you treat him?How should you treat him?

63 Symptoms Increased breathlessness, wheezing, chest tightnessIncreased breathlessness, wheezing, chest tightness Increased cough and sputumIncreased cough and sputum Change in color and/or tenacity of sputumChange in color and/or tenacity of sputum –An increase in sputum volume and purulence points to a bacterial cause Nonspecific complaints: fever, malaise, fatigue, depression, confusionNonspecific complaints: fever, malaise, fatigue, depression, confusion

64 Assessment of severity of exacerbation Peak flow <100 L/min or FEV 1 <1.0 L indicates severe exacerbationPeak flow <100 L/min or FEV 1 <1.0 L indicates severe exacerbation ABGABG CXRCXR EKGEKG D-dimer, spiral CTD-dimer, spiral CT Sputum cultureSputum culture

65 Manage Exacerbations: Key Points Inhaled bronchodilators (Beta 2 -agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocortico- steroids are effective for the treatment of COPD exacerbations (Evidence A).Inhaled bronchodilators (Beta 2 -agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocortico- steroids are effective for the treatment of COPD exacerbations (Evidence A). 80% of AECB are infectious. Environmental factors and medication nonadherence are 20%.80% of AECB are infectious. Environmental factors and medication nonadherence are 20%.

66 Manage Exacerbations: Key Points Noninvasive intermittent positive pressure ventilation (NIPPV) in acute exacerbations improves blood gases and pH, reduces in- hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A).Noninvasive intermittent positive pressure ventilation (NIPPV) in acute exacerbations improves blood gases and pH, reduces in- hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A).

67 NIPPV Selection criteria:Selection criteria: –Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion –Moderate to severe acidosis and hypercapnia –Respiratory frequency >25/min Exclusion criteria:Exclusion criteria: –Respiratory arrest –Cardiovascular instability –Somnolence, impaired mental status, uncooperative patient –High aspiration risk –Viscous or copious secretions –Recent facial or gastroesophageal surgery –Craniofacial trauma –Extreme obesity

68 He is admitted to 5500. How should he be treated? The nurse calls you because the patient is poorly responsive. T 98.6 HR 125 R 16 BP 110/65 Sats 92% on 50% face mask. Patient is barely arousable by sternal rub. What do you want to do now?He is admitted to 5500. How should he be treated? The nurse calls you because the patient is poorly responsive. T 98.6 HR 125 R 16 BP 110/65 Sats 92% on 50% face mask. Patient is barely arousable by sternal rub. What do you want to do now?

69 Which of the following is NOT true about this patient?Which of the following is NOT true about this patient? A. His inpatient mortality rate is 25%.A. His inpatient mortality rate is 25%. B. If he survives this hospitalization, he is likely to be readmitted within 6 months.B. If he survives this hospitalization, he is likely to be readmitted within 6 months. C. This is the ideal time to discuss code status with the patient’s family.C. This is the ideal time to discuss code status with the patient’s family. D. The patient’s five year mortality is 70%.D. The patient’s five year mortality is 70%.

70 Retrospective study of 57 patients with COPD admitted to the ICU with a COPD exacerbationRetrospective study of 57 patients with COPD admitted to the ICU with a COPD exacerbation 90% intubated90% intubated In-hospital mortality 24.5%In-hospital mortality 24.5% Median survival 26 monthsMedian survival 26 months Mortality rate at 5 years 69.6%Mortality rate at 5 years 69.6% Chest 2005; 128:518-24Chest 2005; 128:518-24


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