COPD Update Chronic Obstructive Pulmonary Disease David Henke MD, MPH N Engl J Med 356;8 Feb. 2007

Kurosawa, H. et al. N Engl J Med 2004;350:1036 Dynamic Narrowing

Diagnosis of COPD Symptoms Cough Sputum Dyspnea Exposure to risk factors Tobacco smoke Occupation Indoor/outdoor pollution Spirometry GOLD Guidelines, 2001.

What Happens To Smokers? Doll-BMJ June 26;328(7455):1519  50% of Persistent Smokers Killed By Their Habit - 25% age  Full Impact On National Mortality Takes > 50 Years To Realize  Smoking Doubles Age Specific Mortality In Middle & Old Age  Longevity Has Improved Rapidly But Not For Smokers  Stopping At 50 Y.O. Halved The Hazard  Stopping At 30 Y.0. Avoided Most Of the Risk  Smokers Die About 10 YRS. Younger

Combination ICS & Long-acting Beta agonists (LABA) outcome: 18% reduction of all-cause death over 3yrs. Intention to Rx: 39 pts to save 1 life over 3yrs. P=0.052 Mono-therapy ICS associated with more pneumonia No adverse risk with LABA therapy (not powered for African Americans) Combination Therapy verses either mono-therapy: –Better health status –Fewer exacerbations-- –Less oral steroids –Protection against declining lung function NEJM 356;8,2007 (Similar results AJRCCM 175 Jan. 2007) Towards a Revolution in COPD Health (TORCH)

Clinic Patient  65 y.o. white female (60p/y smoker)w/o sx’s. Concerned about smoking, husband insisted she see MD.  Performs ADLs, worked as hostess in son’s restaurant  No SOB/DOE.  Mildly obese/ normal physical

What Do I Tell My Patient With A Concerned Husband Who Denies Symptoms? I Don’t Care If You Have COPD Because You Smoke And If You Have It You Deserve It I’ll Give You A Valium Prescription So You Can Sedate Your Hyper-Vigilant Husband You May Have COPD Because You Smoke Even Though You’re Not Aware Of Symptoms. The Only Way To Be Sure Is To Perform Spirometry.

Spirometry

65 y.o. white female (60p/y smoker)w/o sx’s After Bronchodilator Pre % Ref Post % Ref 9 months later FVC 79% 83% (5%) 93% FEV1 51% 57% (12%) 67% FEV1/FVC 49% 53% 55% 25-75% 16% 30% (92%) 32% PEFR L/sec home home 3.75 DLCO 13.5 ml/mmHg/min. %Ref 63% ABG (RA): pH 7.42 CO2= 41 O2=66 % Ref TLC 120% FRC (pl) 137% RV 169% Spirometry CXR: Hyperinflation

86 y.o. male with 90 py smoking D/Ced 1968 with worsening: CRI (Cr.4.7), chronic diarrhea (?etiology), HTN, s/p CVA, s/p biliary stent. CC: 7months of progressive DOE; new supplemental O2 need HPI: Still active and into his business office daily without dyspnea until 7 mos. PTA developed SOB walking from the car to office. Patient now wheelchair dependent and unable to work. Progressive Dyspnea In COPD Page 1/3: case

Spirometry: (PRE) (POST) FVC 4.15 (101%) 4.37 (106%) FEV (86%) 2.73 (95%) FEF (50%) 1.54 (82%) Pulmonary Function Test Case Page 2/3: case Diffusion: DLCO ml/mmHg/min: 8.1 (35%) DLCO/Va ml/mmHg/min: 1.51 (45%) 6 min. walk : Sats 80’s% ABG / RA : pH 7.39 PaO2: 58 mmHg PaCO2: 23 mmHg

High Probability VQ For Pulmonary Embolus Page 3/3: case Most COPD pts die from extra- pulmonary dz, e.g., 25% of severe exacerbations w/o clear cause & resulting in hospitalizations had PEs. (Ann Intern Med. 2006;144:390)

Summary Relay on Risk & Spirometry (symptoms) to dx COPD Therapeutic cornerstone in smokers with COPD: Smoking Cessation Only smoking cessation and maintaining Hgb sats. > 90% prolong life Early detection & Rx for COPD can preserve & improve lung function (Combination vs ICS or B-agonist mono-RX: may be the more effective) Most COPD patients die from non-pulmonary dz