1. 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

2. 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

3. 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

4. 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”

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

6. 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 Jul 27;294(4):482-7.

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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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)

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

16. 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

17. Risk of death in Asthma Frequent hospitalizations Intubated for asthma
Poor perception of airflow obstruction
Frequent albuterol rescue medication use
Psychosocial problems