COPD and Asthma

Objectives „

Review COPD & Asthma Definitions „ Epidemiology „ Clinical features „ Diagnosis, Di i DDx DD „ Therapy in acute exacerbations „ Management M off chronic h i di disease „

VENN Diagram of Reactive Airways Disease

Patient Presentation „

70 year old woman presents to clinic for a routine physical. She has a 100 pack year hi t history off tobacco t b use. Upon direct questioning she endorses increasing SOB, DOE and chronic cough productive of clear sputum. sputum

-How How do we start working her up? - How do we monitor her disease progression? - What are the appropriate treatments?

Definition of COPD “Chronic obstructive obstr cti e pulmonary p lmonar disease (COPD) is a preventable pre entable 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. reversible. The airflow limitation is usually progressive p g and associated with an abnormal inflammatoryy response of the lungs to noxious particles or gases.” - Definition from Global Initiative for Chronic Obstructive Lung Disease

Mortality/Prevalence „

It is estimated that approximately eight percent of all individuals have COPD, including d approximately ten percent of individuals d d older than 40 years.

„

COPD mortality for both men and women have been increasing.

„

**COPD C mortality o ta ty trends t e ds are a e several seve a decades behind be d smoking s o g trends.

„

COPD was the sixth leading cause of death worldwide in 1990 and is expected to become the third leading cause of death by 2020

Percent Change in Age Age--Adjusted Death D hR Rates, U U.S., S 1965 1965--1998 P Proportion ti off 1965 R Rate t 3.0 25 2.5

Coronary Heart Disease

Stroke

Other CVD

COPD

All Other Causes

–59% 59%

–64% 64%

–35% 35%

+163% 163%

–7% 7%

2.0 1.5 10 1.0 0.5 0

1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 Source: www.goldcopd.com

Numb ber Deaths x 1000

COPD Mortality M li 1980 1980--2000 70 60 Men

50 40

Women 30 20 10 0 1980

1985

1990

1995

2000

Source: US Centers for Disease Control and Prevention, 2002 From www.goldcopd.com

COPD: Risk Factors „

„ „ „

Smoking g „ Dose-response relationship „ 90% of all COPD patients are smokers „ Significant Si ifi slowing l i off decline d li in i lung l function f i with i h smoking ki cessation „ 15-20% of smokers receive dx of COPD, although majority will develop some airflow obstruction. Air pollution Occupation (toluene (toluene, cotton mills) Genetics (alpha-1 anti-trypsin deficiency)

Making the Diagnosis Classic History: y „ Usually 20+ pack year history. „ Chronic cough, sputum production, dyspnea. dyspnea. „ Chronic productive cough begins around age 40. „ DOE develops in mid 6060-70s. „ Sputum production is usually insidious; starting in the AM. It is normally mucoid but becomes purulent during an exacerbation. „ Late stage may have early AM headaches, weight loss.

Classic Division: Chronic Bronchitis „

„ „ „ „ „

Characterized by cough productive of sputum on most days for at least 3 months over 2 consecutive years. Disease of the small airways Severe hypoxemia and hypercapnia “Blue Blue bloater bloater” Pulmonary HTN, cor pulmonale Cyanotic, obese, edematous, rhonchi and d wheezes h

Classic Division: Emphysema „

„

„ „

„ „

Dilation/destruction of airspaces Ch Characterized i db by severe dyspnea + mild cough Mild hypoxemia Affects the lung parenchyma “Pink puffer” Tachypnea, noncyanotic, thin diminished breath thin, sounds

Making the diagnosis: 3 Presentations „

1 - Sedentary lifestyle, few complaints. Unaware of the extent of their limitations due to respiratory symptoms. Unknowingly avoiding exertional dyspnea dyspnea..

„

2 – Presenting complaint is respiratory symptoms, dyspnea and chronic cough. g Dyspnea p usually only on exertion first, but becomes progressive. Cough is accompanied by sputum production

„

3 – Acute presentation with wheezing, dyspnea, dyspnea, increased cough and sputum. Often initially dx of asthma, with recurrences.

COPD: Exam „

„

Chest: barrel-chest, tachypnea, diminished breath sounds throughout, hyperresonance, rhonchi or wheezing (esp w/ forced expiration), prolonged expiratory i phase, h lloud d P2 P2. Other: diminished heart tones, digital clubbing, accessory muscle l use, pursed d lips, cyanosis, peripheral edema, cachexia.

Use of Spirometry in Evaluation „ „

„ „ „ „

Pulmonary function tests (PFTs) - Used to diagnose, diagnose determine severity, severity and follow progression COPD is diagnosed when a patient has airflow obstruction (defined as FEV1/FVC 3 mg/L) Age A over 70 Increased emphysema and/or blood flow to the lower lung zones

Prognosis – FEV1

Predictors of mortality in chronic obstructive pulmonary disease. A 15-year follow-up study. T Traver GA; GA Cli Cline MG; MG Burrows B B SO Am A Rev R Respir R i Dis Di 1979 19 9 Jun;119(6):895-902. J 119(6) 895 902

Prognosis: BODE Index „

„

„

The four factors included in the index: „ B - BMI weight i ht (BMI) „ O- Obstruction (FEV1) „ D - Dyspnea (Dyspnea score) „ E - Exercise capacity (six-min) This index provides better prognostic information than the FEV1 alone and can be used to assess therapeutic th r p ti response. r p The utility of the BODE index is not confined to assessing the risk of death; it can also predict h hospitalization. l 4 year survival 0-2 pts 80% 3-4 67% 5-6 57% 7-10 18%

Celli, B. et al. N Engl J Med 2004;350:1005-1012

Wh are kkey aspects off chronic What h i management??

COPD: Chronic management „

„

„

„ „

„

Smoking cessation „ Slows Sl ddecline li iin FEV1 FEV1, decreases d mortality. li Oxygen therapy – Decreases mortality. „ If Pa02 80%, FEV1/FVC