1. COPD Joshua Jewell

2. Epidemiology 8% of all individuals 10% age >40 6 th leading cause of death worldwide 1990 4 th in U.S. - >120,000 Expected 3 rd 2020

3. Impact NHBLI 2005 $38.8 billion – $21.8 billion direct – $17 billion indirect 2006 – COPD to cost > 800 billion over next 20 years 2005 estimate of $3,000-6,000 annual cost per pt Excess annual cost of $6,000

4. Definition “COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases” NHLBI and WHO

5. Types Chronic bronchitis Emphysema Asthma Mixed Variety

6. Evaluation History – Family – Smoking – Environmental Symptoms – Cough – Dyspnea – Sputum Production – Wheeze – Recurrent Respiratory Illness Physical Exam

7. Evaluation Pulmonary Function Tests – GOLD criteria Imaging – CXR – 50% sensitivity – CT ABG

8. CXR

9. Imaging

11. Staging GOLD – FEV1/FVC <70% – I Mild ≥ 80% – II Moderate 50% ≥ - <80% – III Severe 30% ≥ - <50% – IV Very Severe <30% BODE – FEV1 – 6 min walk test – MMRC dyspnea scale – BMI

12. Treatment Goal Prevent and decrease symptoms Reduce frequency and severity of exacerbations Improve health status Improve exercise capacity Improve overall associated health care costs

13. Therapy Patient education Avoid risk factors Annual flu vaccine Pneumococcal vaccine 0xygen therapy Pulmonary rehabilitation

14. Management Mild COPD – PRN SABA Moderate COPD – PRN SABA – Single or double long acting bronchodilator – Rehabilitation

15. Management Severe COPD – PRN SABA – Long acting bronchodilator – generally two forms – Rehabilitation – +/- Inhaled glucocorticoid therapy

16. Management Very Severe COPD – PRN SABA – Combination long acting bronchodilator therapy – +/- ICS – Treatment of complications – Rehabilitation – +/- oxygen therapy – ? Surgical treatments

17. Acute Exacerbation NHLBI and WHO “acute increase in symptoms beyond normal day-to-day variation” – Cough increasing in frequency and severity – Sputum production increase in volume and/or changes character – Increase in dyspnea 70-80% due to respiratory infections

18. Evaluation History and physical Cxr Routine labs ABG Sputum gram stain with c/s

19. Evaluation for Hospitalization Inadequate response of symptoms to op management Marked increase in dyspnea Inability to eat or sleep due to symptoms Worsening hypoxemia Worsening hypercapnea Changes in mental status Inability to care for oneself Uncertain diagnosis High risk comorbidities

20. Treatment SABA Short acting anticholinergic bronchodilators Glucocorticoids – Oral vs IV Empiric antibiotic therapy Supplemental oxygen +/- Mechanical Ventilation

21. Prognosis and Prevention 14% 3 month mortality 6 and 12 month mortality 33 and 43% for acute exacerbation and PaC02 ≥ 50mmHg Upon Resolution insure – Smoking cessation – Avoidance of environmental triggers – Pulmonary rehabilitation – Proper use of medications – Update vaccinations – “action plan” – via PCP

22. MILD Exacerbation 45 yo smoker presents to ED w 5 day h/o cough, yellow sputum, low grade temp. Ran out of albuterol today. Never intubated. Vitals 94% on ra, rr 20/min. Exam w moderate wheeze. CXR negative. – Steroids – Short acting bronchodilators – +/- Abx Discharge with PCP follow up, counsel on tobacco cessation

23. Moderate 65 yo smoker, h/o htn/cad/dm, presents w sob, cough, yellow sputum and cp. Was able to only sleep few hours last night, upright in chair. Used nebs q4 hours x 2 days. Admitted twice in past 2 years for COPD exacerbation, never intubated. Vitals 91% on ra, rr 30/min, diffuse wheeze. CXR, ecg, trop unremarkable. While in ED albuterol/ipatroprium nebs x 4, prednisone, and avelox with good effect. After 4 hrs pt felt much better, upon ambulation w pulse ox pt desaturated to 86% on ra and became very sob. Admit to medical floor Steroids Scheduled/prn breathing treatment Antibiotics Sputum culture/sensitivity Smoking cessation counseling

24. Severe 65 year old smoker, h/o cad s/p 3v cabg, dm, and htn; was up all night using a nebs every 2-3 hrs. Pt only able to speak in short sentences. On arrival, the O2 sat was 84% on ra and rr was 35/min. In route, pt received albuterol and ipatropium nebs. In ED, the pt is using accessory muscles, intercostal retractions, and has pursed lip breathing w blue lips. Additional nebs tx and iv steroids are given with minimal improvement. Pt receives broad spectrum abx. Cxr and EKG show no acute changes. NPPV is applied. Initially pt improves with a decreased work of breathing. However, after 1 hr the pt becomes more somnolent with a decreased rr. An ABG is obtained with a 7.25/60/59/89% – Intubate – Inhaled therapy – Steroids – Abx – Sputum c/s – Basic lab evaluation – Repeat abg at 1 hour