Download - Back to Basics Review: Respirology in Under Two Hours Jennifer Block, MD, FRCPC April 15, 2009
Back to Basics Review:Respirology in Under Two Hours
Jennifer Block, MD, FRCPC
April 15, 2009
The Plan...
• Spirometry
• Asthma
• COPD
• Sleep Apnea
• Pleural Effusion
Spirometry
1. Take as deep a breath as possible2. Blast out the air into spirometer3. Continue exhaling for several more seconds
UpToDate
RVTLC
Interpretation
• Upper Airway Abnormalities
• Obstructive Lung Disease
• Restrictive Lung Disease
Upper Airway Abnormalities
ERJ 2005; 26: 948-968
Normal Restrictive Obstructive Fixed Intrathoracic Extrathoracic Variable
Obstructive Lung Disease
• FEV1/FVC is <70%
• “scooped out”
• lung volumes may show hyperinflation
ERJ 2005; 26: 948-968
Restrictive Lung Disease
• TLC < 5th percentile predicted
• normal FEV1/FVC ratio
ERJ 2005; 26: 948-968
Asthma
• Pathophysiology
• Diagnosis
• Chronic Management
• Acute Management
Asthma: Definition
• paroxysmal or persistent symptoms (dyspnea, chest tightness, wheeze, cough)
• variable airflow limitation and airway hyper-responsiveness
• due to inflammation
Asthma
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
• If FEV1 is low, try to increase it using a short-acting
bronchodilator (reversibility)
• ≥12% and ≥180 ml improvement in FEV1 from baseline 15
minutes after the use of an inhaled short-acting
bronchodilator
Asthma Diagnosis
• If FEV1 is normal, try to see if airways are hyperresponsive
by giving an irritant (methacholine challenge)
Asthma Diagnosis
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
Asthma Management
Relievers – Short Acting Beta-Agonists
• SABAs for acute relief• ‘rescue’ medication used prn• MDI salbutamol (Ventolin) • dry powder terbutaline (Bricanyl)
Asthma Management
Inhaled Corticosteroids (ICS)
• Anti-inflammatory ICS mainstay of therapy
– Prevent symptoms, improve PFTs, decrease hyper-responsiveness, reduce morbidity
Inhaled Corticosteroids – How do they work?
• Like steroids produced endogenously by adrenal cortex
• Anti-inflammatory – inhibit production of cytokines, which:
– reduces eosinophil infiltration– inhibits macrophage function– reduces production of leukotrienes
Dosing Guide
Drug Low Daily Dose (μg)
Medium Dose (μg)
High Daily Dose (μg)
Fluticasone(Flovent)
≤250 251-500 >500
Budesonide(Pulmicort)
≤400 401-800 >800
Beclomethasone(Qvar)
≤250 251-500 >500
Ciclesonide(Alvesco)
≤200 201-400 >400
ICS Adverse Effects
• thrush• dysphonia
• osteoporosis• growth velocity• glaucoma • cataracts• adrenal insufficiency
Asthma Management
Long Acting β2-Agonists (LABAs)
• add if not controlled by moderate dose ICS
• better than doubling ICS
• “not recommended as maintenance monotherapy”
• doesn’t replace SABAs
• salmeterol (Serevent), formoterol (Oxeze)
Combination LABA / ICS Products
– Salmeterol/fluticasone (Advair) MDI and diskus
– Budesonide/formoterol (Symbicort) turbuhaler
Leukotriene Receptor Antagonists (LTRAs)
• Second or third choice medication or in patients who can’t take ICS
• Montelukast (Singulair)
• Oral medication
• Use in patients with:
– symptoms despite LABA/ICS
– ASA sensitivity, nasal polyps
– exercise-induced asthma
IgE Antagonists: Omalizumab (Xolair)
• Monoclonal antibodies block action of IgE on mast cell
• Effective if IgE levels are only slightly elevated (500-1200)
• Monthly injection
• Extremely expensive $45,000/year
• Use if frequent need for oral steroids despite optimum conventional Rx and patient has drug plan or $$$
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
Assess Control
Comprehensive Asthma Management
• Suspect asthma and confirm diagnosis
• Education
• Assess severity
• Avoid / control triggers and environmental modification
• Medications for chronic disease
• Assess control
• Management plan for exacerbation
• Regular follow-up
Asthma Exacerbation
• ABC’s– include RR, O2 sats, assess work of breathing, wheezing
• history: – diagnosis– triggers– previous exacerbations/admissions/intubations– treatment history
• identifiable trigger
• short-acting beta-agonists ie. salbutamol (Ventolin)
• short-acting anti-cholinergics ie. ipratropium (Atrovent)
• systemic anti-inflammatory therapy– oral = prednisone– intravenous = solumedrol
• very severe: MgSO4, intubation, anesthetic
Asthma Exacerbation
COPD
• Contrast from asthma
• Definition
• Pathophysiology
• Diagnosis
• Chronic Management
• Acute Management
COPD Definition
• respiratory disorder largely caused by smoking characterized
by:
- progressive, partially reversible airway obstruction
- hyperinflation
- systemic manifestations
- increasing frequency and severity of exacerbations
COPD Risk Factors
• Host Factors:
- genetics (alpha-1-antitrypsin deficiency)
- bronchial hyper-responsiveness
• Environmental Factors:
- smoking
- childhood viral infections
- occupational & environmental exposures
Pathophysiology - Airflow Obstruction
• alveoli and support structures are destroyed– decreased elastic recoil– lack of tethering gives airway collapse
• airway compression by adjacent overdistended lung units
• mucosal inflammation and secretions
Pathophysiology - Hyperinflation
• expiratory flow limitation in COPD gives air trapping
• end-expiratory lung volumes are increased
• further hyperinflation with exercise (increased RR, decreased expiratory time)
• decreased inspiratory capacity a major cause of dyspnea
COPD Diagnosis
• do not screen asymptomatic individuals
• assess symptomatic patients with spirometry
• post-bronchodilator FEV1/FVC ratio less than 0.7
COPD StagePost-bronchodilator FEV1
(% predicted)
mild ≥ 80
moderate 50 - 79
severe 30 - 49
very severe < 30
COPD Management
BMJ 2008; 336: 598-600.
Education - Effects of Smoking on FEV1
Education
“Tobacco is the only legal consumer product that kills
one third to one half of those who use it as intended
by its manufacturers, with its victims dying on
average 15 years prematurely”
- World Health Organization
Canadian Tobacco Use Monitoring Survey (CTUMS)
•telephone survey with 9547 respondents performed in first six months of 2007•19% population current smoker (male>female)
– 15% of youth age 15-19 [vs. 28%]– 24% of adults age 20-24 [vs. 34%]
Smoking in Canada
What Can You Do?
• smoking cessation advice– even brief advice increases chances of patients quitting– www.gosmokefree.ca– www.smokershelpline.ca
• nicotine replacement therapy– many different types– any form of NRT increases chances of quitting vs.
control
Other Prevention
• vaccination:– flu vaccine yearly– pneumococcal vaccine q5years
COPD Management
Short-Acting Bronchodilators
• Even patients with “fixed” airflow obstruction can have good clinical response to bronchodilators even if FEV1 changes very little
• Reduces hyperinflation, reduces dyspnea and increases exercise capacity
Short-Acting Bronchodilators
• anti-cholingergics: ipatropium (Atrovent)– bitter taste– dry mouth– glaucoma if sprayed into eye– urinary retention
• β2-agonists: salbutamol (Ventolin)– tachycardia, palpitations– sleeplessness, tremor
• improves PFTS, dyspnea and exercise performance
COPD Management
Long-acting anti-cholinergic
• tiotropium (Spiriva)
• once a day
• blocks M3 muscarinic receptors in bronchial smooth muscle
• improves:– PFTs, dyspnea, exercise capacity, QOL– decreases exacerbations– maybe more improvement than LABA
Long-acting β2-agonist (LABA)
• salmeterol (Serevent) and formoterol (Oxeze)
• twice daily
• more sustained improvement in PFTs, dyspnea and QOL
compared with SABA– effect on exercise capacity not clear– decrease exacerbation
COPD Management
Dyspnea – Downward Spiral of Deconditioning
Respiratoryimpairment
Dyspnea during moderate exertion
Abstentionfrom exercise
Physical deconditioning
Dyspnea during mild exertion
Furtherabstention
Furtherdeconditioning
Dyspneaduring ADL
*
* = stay at home. Depression, oxygen
therapy etc.
Pulmonary Rehabilitation
– Exercise + psychosocial support
– Aerobic exercise + strength training
– improves dyspnea, endurance, QOL
– trend to decreasing mortality
– need a maintenance program
www.lungchicago.org www.altru.org
COPD Management
Combination LABA / ICS Products
– Salmeterol/fluticasone (Advair) MDI and diskus
– Budesonide/formoterol (Symbicort) turbuhaler
– add to therapy if patient has persistent dyspnea or recurrent exacerbations
– improve PFTs, QOL, decrease exacerbations
– no ICS monotherapy
COPD Management
Indications for long term oxygen therapy
• pO2 on room air of≤ 55 mmHg< 60 mm Hg if evidence of
– Polycythemia– Cor pulmonale– Right heart failure
• Mortality benefit
COPD Management
Surgery
• Lung Volume Reduction Surgery- benefits patients with upper lobe (heterogenous)
emphysema and poor exercise capacity
• Lung Transplantation- single or double lung- non-smoker- generally age<60 without significant cardiac, renal,
hepatic disease- post-transplant survival is 5 years on average- death from infection (early) and chronic rejection (later)
COPD Management
End of Life Issues
• Empathetic, realistic conversations about illness• Opportunity to express wishes re: intubation
• Dyspnea- morphine po, sc, iv or - morphine nebulized 5 mg in 2 ml normal saline q4h- benzodiazepines
• Cough- opioids (codeine, morphine)
• Secretions- scopolamine
What Decreases Mortality?
Non-Pharmacologic• Smoking cessation Yes• Flu shot No• Pneumonia vaccine No• Pulmonary Rehab ?
Pharmacologic
• Oxygen Yes
• Systemic Steroids No
• Antibiotics No
• SABA (Ventolin) No
• Anti-cholinergics No
• Theophylline No
• Inhaled Steroids No
• LABAs No
• Combo ICS/LABA No
Acute exacerbations of COPD
• Definition: Anthonisen criteria. Require 2 of:– Increased dyspnea– Increased volume of sputum– Increased purulence of sputum
• Over 50% are associated with an infection
Acute exacerbations of COPD
• Treatment:
– ABCs
– O2 sat monitoring and oxygen prn
– history and p/e to rule out other causes of dyspnea
– CXR, ABG, sputum C&S
– short-acting bronchodilators: salbutamol + ipatropium
– systemic steroids: prednisone 30-40 mg/d x 10-14 days
– antibiotics if purulent sputum
– NIPPV
No modifying factors Macrolide Doxycycline
COPD w/o recent rx New macrolide Doxycycline
COPD w/ recent rx Resp fluoroquinolone Cephalosporin or amox/clav plus macrolide
Macro-aspiration Amox/clav Respiratory fluoroquinolone
plus plus
Macrolide Metronidazole or clindamycin
CTS/CIDS Guidelines for Management of CAP 2000
Outpatients
Ward Admission Respiratory fluoroquinolone Cephalosporin plus Macrolide
Intensive Care Unit Respiratory fluoroquinolone Macrolide plus plus 3rd gen Cephalosporin 3rd gen Cephalosporin or or b-lactam/b-lactamase inhibitor b-lactam/b-lactamase inhib
CTS/CIDS Guidelines for Management of CAP 2000
Inpatients
Not all that Wheezes...
• is asthma or COPD
• can also be heard in patients with bronchiectasis, cystic fibrosis, pulmonary edema
Obstructive Sleep Apnea Syndrome
• Snoring, witnessed apneas
• Morning headache, daytime sleepiness
• Sleep study = Polysomnography
– EEG to stage sleep– Electro-oculography– EKG– Oronasal airflow– Respiratory effort– SpO2
Obstructive Sleep Apnea Syndrome
• Respiratory Disturbance Index (RDI):– normal <5/hour– mild 5-15/hour– moderate 16-30/hour– severe >30/hour
• Treatment:– weight loss, avoid sedatives– positional therapy (off supine)– CPAP– oral appliance, tracheostomy less common
Pleural Effusion
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
Pleural Fluid Accumulation
• In normal pleural space, the rate of fluid formation is balanced by the rate of removal
• Rate of fluid formation is determined by the Starling equation which describes a semi-permeable membrane
– hydrostatic forces push water out of vessel
– osmotic forces pull water back into vessel
• Pleural effusion is due to abnormalities in one of these processes
• Cell count and differential• Gram stain• Culture• AFB• Cytology
• LDH• Total protein• Glucose • pH
Pleural Effusion Evaluation
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
Light’s Criteria•pleural fluid protein/serum protein > 0.5•pleural fluid LDH / serum LDH > 0.6•pleural fluid LDH > 2/3 upper limit normal LDH
Any of these three criteria means fluid is EXUDATE
Pleural Effusion Evaluation
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
Many!
Transudate = heart, liver, kidney
Exudate = infectious inflammatory malignant movement from abdomen iatrogenic
Pleural Effusion Etiology
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
• If exudate with no determined cause, you want to rule-out malignancy
repeat thoracentesisCT chest with contrastpleuroscopy or VATSbronchoscopyfollow and repeat
Pleural Effusion Etiology
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
Most places, patients admitted for symptomatic thoracentesis +/- tube drainage and attempt at pleurodesis (talc)
In Ottawa, patients mostly receiving Pleurx catheters to allow home drainage
Malignant Pleural Effusions
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
The Plan...
• Spirometry
• Asthma
• COPD
• Sleep Apnea
• Pleural Effusion