1. Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

2. Outline Introduction and Overview Asthma – Diagnosis and Treatment Chronic Obstructive Pulmonary Disease (COPD) – Diagnosis and Treatment

3. Our Airways NHLBI Website

4. Why Asthma Makes It Harder to Breathe

5. www.iowatracs.us

6. Asthma Guidelines Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program

7. Asthma Definitions Chronic inflammation of airways Airflow obstruction that is REVERSIBLE? (variable) and recurrent – Bronchial hyperresponsiveness – Structural changes in airways – Inflammation (neutrophils, eosinophils, mast cells, etc.) – Atopy (allergic, IgE)

8. EPR 3 Guidelines on Asthma 2007 Update

10. Asthma Clinical Symptoms Recurrent episodes of wheezing (bronchospasm) Breathlessness Cough (particularly at night) Chest Tightness

11. Asthma Diagnosis History and Exam Pulmonary Function Testing Peak Flow Measurements Methacholine Challenge Testing

12. Peak Flow Testing

13. Asthma Therapy Avoidance of Triggers (tobacco smoke, perfumes, dust mites, etc.) Bronchodilators – Albuterol Inhaled Corticosteroids Leukotriene Inhibitors (i.e. Montelukast/Singulair) Anti-IgE Therapy (Xolair) Oral Steroids (Prednisone)

14. Influence of Tobacco Smoke Active smoking increases risk for development of asthma Children of smoking mothers are 2.1 times more likely to develop asthma Weitzman et al. Pediatrics. 1990 Even prenatal exposure to cigarette smoke Cunningham et al. Am J Respir Crit Care Med. 1996 Smoking worsens pre-existing asthma Siroux et al. Eur Respir J. 2000

17. Goals of Therapy Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath) Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms Few night-time awakenings (<2 nights per month) due to asthma Optimization of lung function Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise Satisfaction with asthma care on the part of patients and families

18. Newest Advanced Therapies for Asthma Bronchial Thermoplasty Immunotherapy (mepolizumab)

19. Chronic Obstructive Pulmonary Disease “a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.” - GOLD Guideline 3 rd Leading Cause of Death in the US

20. CODP is often Confused with Asthma

21. COPD – What is the defect? Airflow Limitation – Inflammation, mucus, scarring of airways – Reduction in number of airways – Floppiness of airways Emphysema – Destruction of alveoli and respiratory bronchiole Pulmonary blood vessels – Thickening and loss of small blood vessels

22. NHLBI

23. What causes COPD? Tobacco smoke (at least 25% of all smokers) Løkke et al. Thorax. 2006 Other particulates – Open fire burning – Coal workers, other occupations Genetics (alpha 1 antitrypsin) Pre-existing asthma Age and Gender

24. COPD - Symptoms Shortness of breath (particularly with exercise) Cough (commonly productive of sputum) Recurrent Bronchitis (exacerbations) – Wheezing, sputum production, chest tightness

25. Evaluation Pulmonary Function Testing Gene Testing Chest xray or CT scan optional

26. COPD Treatment Smoking Cessation!! Bronchodilators (hand-held inhalers or nebulizers) – Tiotropium is best example Inhaled corticosteroids Roflumilast Macrolide antibiotics (i.e. azithromycin)

27. COPD Advanced Therapies Oxygen Nocturnal Ventilation (BIPAP) Lung Volume Reduction Therapy

28. COPD Management Goals Improve Quality of Life – Improve Walk Distance Minimize Exacerbations (Bronchitis episodes) Maintain Lung Function Improve Longevity

29. Alternative Diagnoses Cough and Wheeze – Gastroesophageal Reflux Disease – Post-infectious Cough Syndrome – ACE inhibitor induced Cough – Vocal cord dysfunction – Post nasal Drip/Upper Airway Cough Syndrome – Bronchiolitis/Infections Shortness of Breath – Heart Failure – Pulmonary Embolism

30. Conclusion Wheezing, cough and shortness of breath may be presenting features of asthma or COPD. Confirmation of the diagnosis of asthma and COPD is important as treatment and prognosis of both differ, and it is important to distinguish these from other serious conditions. Smoking cessation is key to prevention and treatment of both conditions.

31. Thank you.