Chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease Josh Solomon, MD COPD • • • • Definition Epidemiology Clinical Disease and Diagnosis Exacerbations – Definition – Treatment • Ventilation • Outpatient Treatment Definition • A clinical syndrome characterized by: – Partially reversible airflow limitation – Slow clinical progression – Minimal airway hyperresponsiveness vs asthma • Strongly linked to chronic exposure to tobacco smoke • An inflammatory airway disease Epidemiology • Fourth leading cause of death in the United States • Seen in 10% of adults over the age of 40 globally – Higher in smokers – Higher in men Clinical Disease • Slow onset of progressive shortness of breath • Inability to tolerate physical activity • Increasing frequency of exacerbations • Cough and sputum production Diagnosis Airflow obstruction FVC FEV1 V O L FEV1 U M E FEV1/FVC >70% TIME Spirometric Criteria for COPD • Forced expiratory volume in one second (FEV1) < 80% predicted • FEV1/FVC ratio < 70% • Airflow does not improve ≥12% and 200mL with albuterol Pauwels RA, et al AJRCCM 2001; 163 Fabbri LM and Hurd SS Eur Respir J 2003; 22 Natural History: FEV1 Decline 100 Never-smoker 80 Smoker 60 FEV1 (%) Symptoms 40 Disability 20 Death 20 30 40 50 60 70 80 90 Age (years) Fletcher C, Peto R Br Med J 1977; Treatment •Oxygen •keep SaO2 > 90% but avoid high SaO2 (>97%) •B agonists(albuterol/terbutaline/salbuterol) •Nebulized or MDI have same delivery •inhaled better than intravenous (FEV1) Mcrory et at CHEST 2001; 119 •anticholinergics (ipratropium) •use with beta agonists in inhaled form Treatment •Methylxanthines (aminophylline) •No good data that they work in COPD •Minimal if any improvement in FEV1 •Only use if no access to B- agonists or anticholinergics Barr et al Cochrane Review 2001 Treatment •Antibiotics •All ICU and ventilated patients Saint et al JAMA 1995, 273 •Inpatient – mild •macrolide, fluoroquinolone, 3rd generation cephalosporin, antipseudomonal penicillin •Inpatient – sick (ICU) •3rd generation ceph/antipseudomonal PCN + fluoroquinolone or aminoglycoside Treatment •Steroids •studies show shorter hospital stay and faster improvement in FEV1 Niewoehner et al NEJM 1999, 340 •Severe disease •methylprednisolone 0.5 to mg/kg every hrs for days, then prednisone 40 mg for weeks •slow taper in severe disease COPD and respiratory failure •Non-invasive ventilation •studied in COPD – prevents intubation and improves outcome in respiratory failure Brochard et al NEJM 1995, 333 •Contraindications : altered mental status, increased secretions, CV instability COPD and respiratory failure •Ventilation Goals •rest muscles of breathing •allow time for exhalation •prevent hyperinflation COPD and respiratory failure •Ventilation •Volume Control •Vt – – 10 cc/kg body weight •RR – use to target normal or patients CO2 •PEEP mm H2O •I:E 1:3 to 1:5 (**important long expiratory time) •#1 risk is HYPERINFLATION Hyperinflation • Increased volume of lung at end • • expiration Causes - expiratory airflow obstruction + inadequate expiratory time Signs - hypotension, high airway pressures, hypoxemia, pneumothorax Hyperinflation • Measure - breath hold at end expiration (iPEEP, autoPEEP) Hyperinflation Treatment • Increase expiratory time – – – – Decrease respiratory rate Decrease tidal volume Increased flow rate/change I:E ratio Tolerate higher CO2 levels • Decrease airflow obstruction – Aggressive use of bronchodilators – Sedation/paralysis if necessary COPD and respiratory failure •Ventilation •Extubate as soon as patient tolerates a 30 minute wean •Target patients baseline CO2 •Can extubate early to noninvasive Ferrer et al AJRCCM 2006; 173 Discharge •Smoking cessation #1 •inhaled albuterol/salbuterol + ipratropium •slow prednisone taper(2 weeks minimum) •oxygen if SaO2 [...]... Shortness of breath • Amount of sputum • Color of sputum • Requires change in medication • Increase in frequency as disease gets more severe Exacerbation •infection account for 80% of exacerbations •Strep Pneumonia, Hemophilus influenza, Moraxella catarrhalis most common •Other causes include pulmonary embolism, heart failure, pneumothorax Sethi et al CHEST 2001; 115 Workup • History/physical exam • Chest... aminoglycoside Treatment •Steroids •studies show shorter hospital stay and faster improvement in FEV1 Niewoehner et al NEJM 1999, 340 •Severe disease •methylprednisolone 0.5 to 1 mg/kg every 6 hrs for 3 days, then prednisone 40 mg for 2 weeks •slow taper in severe disease COPD and respiratory failure •Non-invasive ventilation •studied in COPD – prevents intubation and improves outcome in respiratory failure