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Management of Chronic Airflow Obstruction J.R. Sheller, M.D. Allergy, Pulmonary & Critical Care Medicine
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Chronic Airflow Obstruction Asthma COPD – emphysema/chronic obstructive bronchitis Bronchiectasis – cystic fibrosis Obliterative bronchiolitis
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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
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Spirometry
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Functional residual capacity
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FEV 1 (%) max Time (yrs) 80 2040 100 50 Disability Death
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FEV 1 (%) Time (yrs) 80 2040 100 50 Disability Death
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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
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Bronchodilators Beta 2 adrenergic agonists –By metered dose inhaler –By nebulizer Short acting – albuterol, terbutaline – rescue medicine Long acting – salmeterol, formoterol –Not used for “rescue”
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Anticholinergics Ipratropium Tiatropium Work best in COPD Viral exacerbations of asthma in children
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Theophylline Methylxanthines – adenosine antagonists, phosphodiesterase inhibitors, induces histone deactylase Narrow therapeutic window Not important in emergency May help in difficult cases Phosphodiesterase 4 inhibitor
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Antiinflammatory R X Can improve function Can improve symptoms Uncertain if it alters natural history May affect structural changes (remodeling)
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Inhaled Corticosteroids Topically active Delivered to the airway First pass liver metabolism reduces systemic availability Unknown mechanism of action
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Inhaled Corticosteroids Theoretical: –suppression of adrenals –growth retardation in kids Known: –oral thrush and vocal cord dysfunction –Increased cataracts –Increased loss of bone
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Beclomethasone – 2 puffs QID Triamcinalone – 2 inhalations TID Fluticasone – 2 inhalations BID (3 strengths) Flunisolide – 2 inhalations BID Budesonide – 2 inhalations BID Convenient, cheap
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Leukotriene Modifiers Zileuton – 5 Lipoxygenase inhibitor Receptor antagonist –Zafirlukast 20mg BID –Montelukast 10mg QD
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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/
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COPD R x 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
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Calls with low grade fever, dyspnea, ankle edema Admitted to hospital with SaO 2 75% Oxygen by nasal prongs BiPAP (non invasive ventilation) Systemic steroids – iv methylprednisolone, convert to oral (60mg prednisone) Nebulized ipratropium/albuterol Pneumovax, influenza vaccine
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Home Oxygen SaO 2 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
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35 year old female with episodic cough, wheezing, dyspnea after jogging Childhood history of asthma Atopic (hay fever) Normal exam FEV 1 normal; FEV 1 /FVC reduced
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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/
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Still having problems with dyspnea, uses albuterol several times a day GERD, Sinus disease Increase inhaled steroids Add leukotriene modifier Montelukast, zafirlukast – receptor blockers Zileuton – inhibitor of 5-lipoxygenase Consider theophylline Anti IgE (omalizumab)
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Has symptoms of URI, using albuterol every 2hrs, not getting relief ED R x –Oxygen –Continuous albuterol –Intravenous methylprednisolone 125mg –Ipratropium –Mg may help those with most severe obstruction –Measure PEFR, FEV 1, pulsus paradoxus –Admit in 2hrs if no improvement
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Risk of death in Asthma Frequent hospitalizations Intubated for asthma Poor perception of airflow obstruction Frequent albuterol rescue medication use Psychosocial problems
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Treatment Scheme Mild intermittent -agonists Mild persistent+ inhaled steroids Moderate salmeterol, more inhaled steroids, leukotriene modifiers Severetheophylline, oral steroids, anti IgE
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