Management of Chronic Airflow Obstruction J.R. Sheller, M.D. Allergy, Pulmonary & Critical Care Medicine Pierre: 42% smoked 30yrs ago, now 22%. Lung Cancer 87% are smokers. It is declining. Feb 6, 2007

COPD DX: Chronic obstructive bronchitis and emphysema 72 year old smoker for 60yrs Cough, sputum production, dyspnea FEV1 33% predicted; DLCO 25% predicted No bronchodilator response to albuterol Rhonchi, wheezes, pedal edema DX: Chronic obstructive bronchitis and emphysema http://www.goldcopd.com/

Check alpha one antitrypsin level Smoking history If absent consider other dx (immunodeficiency, ciliary dysfunction, cystic fibrosis) Check alpha one antitrypsin level In patients with early disease (<45yoa) In patients with family history of COPD

Bronchodilators Beta2 adrenergic agonists By metered dose inhaler By dry powder inhaler By nebulizer Short acting – albuterol, terbutaline – rescue medicine Long acting – salmeterol, formoterol Not used for “rescue”

Anticholinergics Ipratropium Tiatropium Work best in COPD Viral exacerbations of asthma in children

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 Vaccination vs nicotine Cannabinoid receptor antagonist Schroeder SA. What to do with a patient who smokes. JAMA. 2005 Jul 27;294(4):482-7.

Other Treatments Inhaled corticosteroids for severe COPD with frequent exacerbations Antibiotics For increased and purulent sputum (amoxicillin, doxycycline, macrolides, trimethoprim/sulfa) For hospitalized exacerbations – consider broader spectrum (pseudomonas)

Calls with low grade fever, dyspnea, ankle edema, increased sputum 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 Diuretic – furosemide Antibiotics – (levofloxacin, cefipime, etc) Pneumovax, influenza vaccine

COPD Rx Smoking cessation Inhaled ipratropium, beta agonist using MDI Long acting – tiotropium Flu vaccine, pneumovax Antimicrobials for increased sputum (amoxicillin, doxycycline, macrolides, trimethoprim/sulfa) Inhaled corticosteroids for severe dz Pulmonary rehabilitation Avoid oral steroids

Home Oxygen Home oxygen tethers patients, causing deconditioning 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/

Convenient, cheap Beclomethasone – 2 puffs QID Triamcinalone – 2 inhalations TID Fluticasone – 2 inhalations BID (3 strengths) Flunisolide – 2 inhalations BID Budesonide – 2 inhalations BID Convenient, cheap

Still having problems with dyspnea, uses albuterol several times a day GERD, Sinus disease Add leukotriene modifier Montelukast, zafirlukast – receptor blockers Zileuton – inhibitor of 5-lipoxygenase Increase inhaled steroids Consider theophylline Anti IgE (omalizumab)

Leukotriene Modifiers Zileuton – 5 Lipoxygenase inhibitor Receptor antagonist Zafirlukast 20mg BID Montelukast 10mg QD

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