Management of Chronic Airflow Obstruction J.R. Sheller, M.D. Allergy, Pulmonary & Critical Care Medicine

Chronic Airflow Obstruction Asthma COPD – emphysema/chronic obstructive bronchitis Bronchiectasis – cystic fibrosis Obliterative bronchiolitis

12.1 million adults ages 25 and older reported being diagnosed with COPD; 21 million asthmatics Total estimated cost of COPD $32.1 billion, asthma was $13.8 COPD is the fourth leading cause of death in the U.S. and is projected to be the third leading cause of death by the year deaths/yr from asthma

Spirometry

Functional residual capacity

FEV 1 (%) max Time (yrs) Disability Death

FEV 1 (%) Time (yrs) Disability Death

Smoking Cessation Counseling –Has patient thought about stopping? –Rehearse reasons to quit –Offer to help Group therapy – quitting sessions Cancer Society, Heart Assoc., Lung Assoc. Medications –Wellbutrin –Nicotine –Clonidine

Bronchodilators Beta 2 adrenergic agonists –By metered dose inhaler –By nebulizer Short acting – albuterol, terbutaline – rescue medicine Long acting – salmeterol, formoterol –Not used for “rescue”

Anticholinergics Ipratropium Tiatropium Work best in COPD Viral exacerbations of asthma in children

Theophylline Methylxanthines – adenosine antagonists, phosphodiesterase inhibitors, induces histone deactylase Narrow therapeutic window Not important in emergency May help in difficult cases Phosphodiesterase 4 inhibitor

Antiinflammatory R X Can improve function Can improve symptoms Uncertain if it alters natural history May affect structural changes (remodeling)

Inhaled Corticosteroids Topically active Delivered to the airway First pass liver metabolism reduces systemic availability Unknown mechanism of action

Inhaled Corticosteroids Theoretical: –suppression of adrenals –growth retardation in kids Known: –oral thrush and vocal cord dysfunction –Increased cataracts –Increased loss of bone

Beclomethasone – 2 puffs QID Triamcinalone – 2 inhalations TID Fluticasone – 2 inhalations BID (3 strengths) Flunisolide – 2 inhalations BID Budesonide – 2 inhalations BID Convenient, cheap

Leukotriene Modifiers Zileuton – 5 Lipoxygenase inhibitor Receptor antagonist –Zafirlukast 20mg BID –Montelukast 10mg QD

COPD 72 year old smoker for 60yrs Cough, sputum production, dyspnea FEV1 33% predicted; DLCO 25% predicted Rhonchi, wheezes, pedal edema DX: Chronic obstructive bronchitis and emphysema

COPD R x Smoking cessation Inhaled ipratropium, beta agonist using MDI Long acting beta adrenergic - salmeterol Flu vaccine, pneumovax Antimicrobials for increased sputum (amoxicillin, doxycycline, macrolides, trimethoprim/sulfa) Inhaled corticosteroids controversial Avoid oral steroids

Calls with low grade fever, dyspnea, ankle edema Admitted to hospital with SaO 2 75% Oxygen by nasal prongs BiPAP (non invasive ventilation) Systemic steroids – iv methylprednisolone, convert to oral (60mg prednisone) Nebulized ipratropium/albuterol Pneumovax, influenza vaccine

Home Oxygen SaO 2 55, CHF) Should be used 24hrs day After 6 weeks, recheck sats (50% of patients no longer need it) Home oxygen tethers patients, causing deconditioning Pulmonary rehab, activity are important

35 year old female with episodic cough, wheezing, dyspnea after jogging Childhood history of asthma Atopic (hay fever) Normal exam FEV 1 normal; FEV 1 /FVC reduced

Albuterol MDI prior to exercise Medication works, but she uses it each day Add inhaled steroids Now awakening at night with cough Add long acting beta agonist (salmeterol, formoterol; or combination, eg Advair, Symbicort) Rehearse inhaler use, action plan Allergy/Pulmonary consultation

Still having problems with dyspnea, uses albuterol several times a day GERD, Sinus disease Increase inhaled steroids Add leukotriene modifier Montelukast, zafirlukast – receptor blockers Zileuton – inhibitor of 5-lipoxygenase Consider theophylline Anti IgE (omalizumab)

Has symptoms of URI, using albuterol every 2hrs, not getting relief ED R x –Oxygen –Continuous albuterol –Intravenous methylprednisolone 125mg –Ipratropium –Mg may help those with most severe obstruction –Measure PEFR, FEV 1, pulsus paradoxus –Admit in 2hrs if no improvement

Risk of death in Asthma Frequent hospitalizations Intubated for asthma Poor perception of airflow obstruction Frequent albuterol rescue medication use Psychosocial problems

Treatment Scheme Mild intermittent  -agonists Mild persistent+ inhaled steroids Moderate salmeterol, more inhaled steroids, leukotriene modifiers Severetheophylline, oral steroids, anti IgE