utrotat
TRANSCRIPT
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 2020.
• 5000 deaths/yr from asthma
Spirometry
Functional residual capacity
FEV1
(%) max
Time (yrs)80 20 40
100
50
Disability
Death
FEV1
(%)
Time (yrs)80 20 40
100
50
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
• Beta2 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 COPDViral 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 RX
• 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
http://www.goldcopd.com/
COPD Rx
• 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 SaO2 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• SaO2 <89% (or pulmonary hypertension,
Hct >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
• FEV1 normal; FEV1/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
http://www.nhlbi.nih.gov/about/naepp/
• Still having problems with dyspnea, uses albuterol several times a day
• GERD, Sinus disease
• Increase inhaled steroids
• Add leukotriene modifierMontelukast, 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 Rx
– Oxygen– Continuous albuterol– Intravenous methylprednisolone 125mg– Ipratropium– Mg may help those with most severe obstruction
– Measure PEFR, FEV1, 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
• Severe theophylline, oral steroids, anti IgE