COPD & Asthma Final PDF

Asthma p. 491 A chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to various stimuli, resulting in episodic reversible narrowing and inflammation of the airways. Airflow obstruction is often reversible spontaneously or with...

Asthma p. 491 A chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to various stimuli, resulting in episodic reversible narrowing and inflammation of the airways. Airflow obstruction is often reversible spontaneously or with treatment Causes/ Incidence Dust mites, pets, cockroaches, indoor molds, exercise, cigarette smoke Asthma most common chronic respiratory disorder among all age groups worldwide Prevalence highest among non-Hispanic children and Poor adults.  Clinical Presentation Heart rate>110 bpm Hallmark: Episodic wheezing Pulsus paradoxus >12mm Hg associated with dyspnea, cough, Hyperresonance and sputum production Cough Respiratory distress at rest Chest tightness Difficulty speaking in sentences Diaphoresis Use of accessory muscles Respiratory rate >28 bpm Remember ! This Photo by Unknown Author is licensed under CC BY-SA-NC Clinical hallmarks of asthma include episodic wheezing associated with dyspnea, cough, and sputum production Ominous signs include fatigue, absent breath sounds, paradoxical chest/abdominal movement, inability to maintain recumbency, cyanosis, and others.  The 4 objectives of the physical examination of the patient with Asthma Diagnosis is based on Demonstration of episodic symptoms of airflow obstruction (wheeze, cough, SOB) Evidence that airflow obstruction is at least partially reversible Exclusion of other conditions from the differential diagnosis Assessment of Asthma Severity Intermittent Asthma (< 2 episodes/week, BL PFTs normal, 0-1 exacerbations/year and need prednisone): SABA prn (Albuterol) Persistent Mild (associated with expiratory wheezing, 3-6 days/week, > 2 exacerbations/year): low dose ICS or cromolyn or theophylline Moderate (heard both expiratory and inspiratory, during inspiratory only or no wheezing at all, daily symptoms, mild reduction in FEV1, > 2 exacerbations/year): Low dose ICS- medium dose ICS + LABA + Albuterol prn Severe Asthma (labored respirations diaphoresis, anxiety, and breathlessness (e.g. cannot finish a sentence)). May not hear breath sounds during severe, constant symptoms, > 2 exacerbations/year, moderate reduction in FEV1/FVC ratio: high dose ICS + LABA + Albuterol prn, and prednisone PO as last resort  Identification of adverse effects of medications: Beta 2 adrenergic and theophylline: tachycardia and tremors. Inhaled corticosteroids: thrush and dysphonia. Oral (systemic) corticosteroids: central adiposity, hypertension, ecchymoses, cataracts, kyphosis, muscle weakness, AMS Identification of concomitant medical problems Associated with asthma: nasal polyps, allergic rhinitis, sinusitis, eczema GERD, diabetes, glaucoma, hypertension are comorbidities Asthma Labs and Diagnostics Diagnosis is based on 3 components: demonstration of episodic symptoms (wheeze, cough, shortness of breath), evidence that airflow obstruction is partially reversible, and exclusion of other conditions for differential diagnosis CBC Slight elevation of WBC with eosinophilia for pts. with asthma PFTs, Spirometry, Peak Flow PFTs Typical of obstructive dysfunction Spirometry at time of diagnosis to confirm diagnosis of asthma (reduced FEV1 and Fev1/FVC ratio). FEV1 measured after inhalation of bronchoconstrictor agonist aerosol ECG not used in routine diagnosis Sputum cultures Arterial blood and other serum analysis CXR usually normal, may show hyperinflation with severe exacerbation (not used in diagnosis unless being admitted to hospital)  Asthma Differential Diagnosis Upper Respiratory System (Croup, vocal cord dysfunction- VCD) Lower Respiratory System (Pneumonia, COPD) Cardiovascular system (Valvular disease, Cardiomyopathy) Gastrointestinal system (GERD): Heartburn after large or fatty meals or empty stomach, worsens with supine. Cough may be present. Patients with asthma typically present younger, may help to distinguish between conditions such as COPD. Asthma will have SOB, dry cough and wheezing, but acute symptoms respond to a SABA Hospitalization if forced expiratory volume in 1 second (FEV1) is less than 30% or at least 40% predicted value after 1 hour of vigorous therapy Hospitalization may also be recommended if peak flow is less than 60L per min initially or does not improve to 50% predicted value after 1 hour of treatment  Preferred Asthma Treatment for Adults Buttaro, pp. 497 1. Controller medication: ICS/LABA/systemic corticosteroids 2. Reliever medication: SABA/low dose ICS-formoterol/short acting anticholinergics Step 4 Medium dose ICS + LABA For moderate asthma (severely Step 1 Short acting beta 2 agonist (SABA) uncontrolled, daily symptoms, FEV1 Albuterol (Proventil), levalbuterol (Xopenex) PRN For Intermittent asthma (< 2/week) 60-80% predicted) If using more than twice a week, asthma is poorly controlled or having exacerbation Step 2 Low-dose inhaled corticosteroids (ICS) Budesonide (Pulmicort), fluticasone (Flovent HFA) Step 5 High-dose ICS + LABA triamcinolone (Azmacort) Mild persistent asthma (> 2/week) Consultation recommended For severe asthma (daily, nonstop symptoms) Step 3 Low-dose ICS+long acting beta 2 agonist (LABA) Salmeterol (Serevent), formoterol (Peforomist) Combination preparations: Fluticasone+salmeterol = Advair Formoterol+budesonide = Symbicort Step 6 High-dose ICS + LABA + for mild, persistent asthma (> 2/week, most days, some nocturnal) oral corticosteroid AND Consider omalizumab (Xolair) for pts who have allergies Overall Goals of Asthma Provide ongoing maintenance and prevention- obesity, comorbidities such as gerd, OSA, rhinitis, and rhinosinusitis (use intranasal glucocorticoids for rhinitis symptoms) Preventing symptoms Maintaining near-normal pulmonary function Minimizing pharmacotherapy (may aggravate coexisting conditions). Beta blockers and aspirin can adversely effect asthma Minimizing the need for ED visits and hospitalizations Asthma Patient Education Patients and families need education about the following: The disease Monitoring for symptoms and preventing exacerbations Environmental triggers and strategies for minimizing them Individualized asthma management plan Possible side effects of medications to report to the PCP The use of peak flow meter Proper inhaler technique (spacers to improve medication delivery)  Chronic Obstructive Pulmonary Disease (COPD) Progressive, not fully reversible, and associated with an abnormal inflammatory response of the lungs. The loss of small airways contributes to airflow limitation and mucociliary dysfunction (characteristic features). They present most commonly with dyspnea, cough, and sputum production (late in disease course, when irreversible changed have already occurred) Asthma NOT included- although it is small airway inflammation, it’s generally reversible Exacerbation: acute event characterized by dyspnea and/or cough and sputum that worsen over 6 sec indicates COPD To confirm diagnosis (gold standard): Spirometry performed pre- and post- bronchodilator administration to determine if airflow limitation is reversible. Not to be performed during exacerbations (inaccurate results) Patients with suspected COPD are evaluated with Pulmonary Function Tests (PFTs) FVC- how much total volume lung can expel starting at max inspiration FEV1- how much volume can be expelled in first second of forced expiration FEV1/FVC < 70%: indicative of airway obstruction FEV1 and all other measurement of expiratory airflow are reduced TLC, FRC, and RV may be increased FEV1/FVC < 0.70 and FEV1 < 80% indicates COPD and not fully reversible Pulse Oximetry, ECG to detect cor pulmonale CBC, ABGs (necessary), a1-Antitypsin CXR- a low, flattened diaphragm is common finding in COPD patients Flattening of diaphragm (should be dome shaped), blunting of the costophrenic COPD angle (PA), enlarged retrosternal space (lateral), hyperinflation (a lot of black) COPD (left) vs normal (right)  COPD Differential Diagnosis COPD (associated in midlife, smoking, slowly progressive) Asthma-COPD Overlap Syndrome (earlier in life, varying symptoms during early morning/night), family history of asthma/allergies, largely reversible airflow limitations, but can develop COPD later Congestive Heart Failure (fine crackles, pulmonary edema, dilated heart) Pulmonary Edema Bronchiectasis (large volumes of purulent sputum commonly associated with bacterial infection, crackles, bronchial thickening on xray) Tuberculosis (cough lasting > 3 weeks, pleuritic chest pain, hemoptysis with fatigue, weight loss, anorexia, fever, chills, night sweats) Nontuberculous mycobacterial lung disease Lung Cancer Classification of COPD by Severity (see Buttaro p 515) Stage 1 Mild COPD- Mild airflow limitation (FEV1 > 80% predicated). Sometimes chronic cough/sputum production. May not be aware yet that lung function abnormal Stage 2 Moderate COPD- Worsening airflow limitation (FEV1 < 50% and < 80% predicted, Progression of symptoms, with SOB developing with exertion Stage 3 Severe COPD- Further worsening of airflow limitation (FEV1 < 30% and < 50% predicted), increased SOB, and repeated exacerbations (which can have an impact on quality of life/prognosis if FEV1 < 50% predicted) Stage 4 Very Severe COPD- Severe airflow limitation (FEV1 < 30% predicted or < 50% predicted + chronic respiratory failure. Quality of life is very impaired and exacerbations may be life threatening  Pharmacologic Agents for COPD therapy Buttaro, pp. 519 Oral Corticosteroids Methylprednisolone: 40-48 mg daily in 3-4 days divided Anticholinergics: bronchodilator first line for daily symptoms doses (SAMA and LAMAs) Prednisone: 40 mg daily for 5 days (acute exacerbations, Ipratropium bromide (SAMA): 20-40 mcg/inhalation MDI 2-4 puffs replace with inhaled form asap) q 6-8 hours. Must be used regularly (not prn) Aclidinium bromide (LAMA): 400 mcg/inhalation DPI, one Inhaled Corticosteroids (combine with LABA) inhalation BID Beclomethasone dipropionate Tiotropium (LAMA): 18 mcg/inhalation DPI, once daily Budesonide B2-Adrenergic Agonists: bronchodilator first line if Ciclesonide intermittent symptoms (SABA and LABA) Mometasone furoate Albuterol sulfate (SABA): 90 mcg/inhalation, 1-2 puffs q 4-6 hours Fluticasone propionate prn Mild/low risk COPD: Combivent prn Bitolterol mesylate (SABA) Levalbuterol (SABA): 45 mcg/inhalation MDI 2 puffs q 4-6 hours Mild/high risk COPD: LABA or LAMA + ICS Salmeterol xinafoate (LABA): 50 mcg DPI, 1 puff q 12 hr Moderate/low risk COPD: LABA or LAMA + Combivent Formoterol (LABA): 20 mcg/2 mL NS nebulization (CAT score < 10, prn low exacerbation frequency) 4-6 hr duration, not exceed 4-12 inhalations/day for SAMA or 2 Moderate/high risk COPD: LABA + LAMA + ICS + times for LAMA Combivent prn Methylxanthine (Theophylline): 10 mg/kg/day in 4 doses Severe COPD: Combination LABA in One inhaler (Formoterol/budesonide 160/4.6 mcg, 2 inhalations q 12 hr) SABA + SAMA: Ipratropium Bromide/Albuterol 20/100 mcg 1 inhalation q 6 hr LAMA + LABA (CAT > 10, more symptomatic) Phosphodiesterase 4 Inhibitor: Roflumilast for frequent exacerbations COPD Treatment and Patient Education Smoking Cessation Influenza vaccine yearly and PCV20, tdap, and zoster for COPD patients Avoidance of irritants or allergens Postural drainage may clear excess secretions Pulmonary Rehabilitation Exercise Training- extremity and strength training, 10-45 min sessions for 4-6 weeks, pursed lip breathing and controlled coughing startegies Nutritional Support- can have weight loss, eat small, frequent meals MAINSTAY of therapy: Inhaled Ipratropium bromide (Atrovent) or sympathomimetics Inhaled tiotropium bromide (Spiriva) promotes bronchodilators Palliative Care and Hospice services for end-of-life care Asthma COPD Age usually < 45 Age usually > 45 unless alpha 1 antitrypsin deficiency (screen Family history of atopy (eczema, allergic rhinitis) is present for this if < 45) Usually has smoked > 20 pack years Cough, dyspnea, wheezing, chest tightness ONLY during Cough, dyspnea, almost never wheezy (unless during exacerbations exacerbation), right heart failure (JVD, edema) Asymptomatic between exacerbations Symptomatic between exacerbations Exam usually normal if between exacerbations Exam: Decreased breath sounds, hyperresonance, hypoxemia/cyanosis, barrel chest (kyphosis and increased AP diameter, depth of thorax > width), pursed lip breathing, PMI at subxiphoid location PFTs- variably abnormal spirometry: Low FEV1/FVC < 70%, PFTs- persistent abnormal spirometry: Low FEV1/FVC < 70%, low peak expiratory flow, scooped out expiratory flow modest improvement after bronchodilator, but PFTs will volume curve. Will be significant improvement after never be normal albuterol + spirometry normal between attacks Treatment: ICS + LABA, prn SABA (Albuterol) Treatment: Albuterol/Ipratropium = Combivent (SABA+SAMA) Budesonide/Symbicort = Symbicort Fluticasone/Salmeterol = Advair Focus on wheezing differences to identify diagnosis Wheezing etiologies: Inspiratory wheezing (anaphylaxis, vocal cord pathology, goiter), Lower airway (Bronchiolitis, bronchitis, aspiration, HF or cardiac asthma) Asthma COPD