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Stan Kellar , MD

Stan Kellar , MD. Chief of Clinical Affairs, BH NLR Pulmonary Medicine Sleep Medicine. COPD. Physiology. The lungs are filters Filter in oxygen Filter out carbon dioxide (Vascular filter, not part of this discussion). Physiology. Ventilation Perfusion Diffusion. Anatomy.

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Stan Kellar , MD

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  1. Stan Kellar, MD Chief of Clinical Affairs, BH NLR Pulmonary Medicine Sleep Medicine

  2. COPD

  3. Physiology • The lungs are filters • Filter in oxygen • Filter out carbon dioxide • (Vascular filter, not part of this discussion)

  4. Physiology • Ventilation • Perfusion • Diffusion

  5. Anatomy

  6. Inspiration/Expiration

  7. INSPIRATION

  8. Passive Expiration

  9. Forced Expiration

  10. Respiratory bronchiole

  11. Tethering

  12. Normal Conducting System

  13. Alveoli • Surface area equivalent to that of a tennis court. • Very thin.

  14. Alveolar and capillary surface

  15. Perfusion • Low pressure bed, PA pressure 30/10. • Approximately 6 billion capillaries in human lung, or about 2000 per alveolus. • Under normal (resting) conditions there is little or no flow to the apices, a waterfall effect.

  16. Ventilation/Perfusion • Under normal circumstances the V/Q (ventilation to perfusion) ratio is 1. • This is altered with decreased perfusion (PE) or decreased ventilation (obstructive lung disease or infiltrative diseases).

  17. Transportation O2 • Primarily by hemoglobulin. • Very little dissolved in plasma.

  18. Transportation of CO2 • 10% dissolved in plasma. • 20 % carried by Hemoglobin. • 70% in form of bicarbonate. • CO2 dissociation curve linear.

  19. COPD • Chronic airflow limitation • Airway inflammation • Affects more than 6% of the population • Third leading cause of death in US • Preventable • Treatable

  20. COPD • Chronic bronchitis-chronic productive cough for three months in two successive years • Emphysema-permanent enlargement of airspaces distal to the terminal bronchioles, loss of alveolar walls • “Asthma”-Reversible airflow limitation

  21. Emphysema

  22. Causes • Smoking-Duration and Amount. PACK YEARS • Threshold? About 25 pack years • Smoking • Smoking • Biomass fuel in developing countries

  23. Incidence • Overall 6.3% USA • Higher in men, lower education level and socioeconomic groups • Incidence increases with increasing age • 3rd to 6th leading cause of death

  24. RISK BY AGE

  25. Pathology • Airway limitation-inflammation • Goblet cell hyperplasia • Mucus plugging • Loss of airway tethering • Loss of airway rigidity • Bronchospasm

  26. Normal Airway

  27. Airway narrowing

  28. Symptoms • Shortness of breath • Cough, with or without sputum • Wheezing • Chest tightness

  29. Dyspnea • Lung disease • Heart disease • Circulatory problems • Neuromuscular diseases • Therefore not all dyspnea is due to lung diseases

  30. Wild Cards • ACID REFLUX • 25% of patients with significant reflux have no reflux symptoms • Another 25% underestimate the degree of reflux • Patients with symptoms have 2x rate of exacerbations • Deconditioning

  31. Physical Findings • Wheezing • Decreased breath sounds • Crackles in bases • Diminished heart sounds • Barrel-shaped chest • Tobacco stained finger tips • Clubbing is rare

  32. Chest X-ray • Normal • Hyperinflation • Bullae • Flattened hemi-diaphragms • Basilar scarring • Unexpected disease-pneumothorax, lung cancer

  33. Hyperinflation

  34. Pneumothorax

  35. Spirometry • FEV1-effort dependent • FVC-effort and time dependent, more than 6 seconds • FEV1/FVC ratio-less than 70% • Peak flow-useful for trends, very effort dependent

  36. Global initiative on chronic Obstructive Lung Disease • GOLD 1: Mild (FEV1 >80% Pred.) • GOLD 2: Moderate (FEV1 50-80% Pred.) • GOLD 3: Severe (FEV1 30-50% Pred.) • GOLD 4: Very severe (FEV1 < 30% Pred.)

  37. COPD Assessment TestOK < 10

  38. Modified Medical Research Council Guide • Please Check Line That Applies to You • Grade 0: I only get short of breath with strenuous exercise. ___ • Grade 1: Short of breath hurrying or up slight incline. ___ • Grade 2: I walk slower on level ground as similar aged individuals • or I stop to rest when walking on my own. ___ • Grade 3: I stop for breath when walking 100 meters or after a • few minutes. ___ • Grade 4: I am too breathless to leave the house or I am • breathless dressing or undressing. ___

  39. RISK • Related to history of exacerbations • Group A: Low risk, less symptoms - GOLD 1-2 and 0-1 exacerbations • Group B: Low risk, More symptoms – GOLD 1-2 and 0-1 exacerbations • Group C: High risk, Less symptoms – GOLD 3-4 and > 2 exacerbations • Group D: High risk, More symptoms - GOLD 3-4 and > 2 exacerbations

  40. Exacerbations • Increased dyspnea • Increased cough • Sputum production • +/- fever • +/- chest pain – chest tightness • Median time between onset of symptoms and onset of treatment 3.69 days

  41. Exacerbation Treatment • Steroids, oral or IV • Antibiotics, oral or IV • Additional bronchodialators • Hospitalization • Non-invasive ventilation • Ventilation • Over 7% do not return to baseline

  42. Hospitalization • Mortality > 10% • Only 75% recover to recent baseline at 5 weeks • 7% have not recovered baseline at 3 months • 63% readmitted during following year • Represents 40-60% of overall cost of care

  43. Hospitalization • Immobilization • Sedation • Hospital acquired conditions • Fragmentation of care – Medication reconciliation – cost of medications – follow-up • Depression - anxiety

  44. Hospital at Home • Population health strategy • Competent caregiver available • In a contained geographic area • Dedicated team of doctor(s), nurses, etc. • Daily visits, possibly including phone or telemedicine visits • Limited care time frame < 15 days

  45. Smoking Cessation • Without help/nicotine replacement-10% • With help/nicotine replacement-50-60% • ASK – ADVISE – ASSESS – ASSIST- ARRANGE • Chantix • Nicotine, Give enough • Too much nicotine causes nausea

  46. Decreased airflow + smoking • Progressive lung disease • 25 times normal risk for heart attack or stroke • 8 times risk for lung, laryngeal, esophageal, stomach, kidney, bladder, oral and pancreatic cancer • Cessation rapidly reduces the risk of cardiovascular complications

  47. Medications: Short actingRescue • Beta agonists, MDI or nebulizer (albuterol) • Techniques • Spacers • Cost • Intended for rescue • Primary side effects cardiac arrhythmia (tachycardia) and tremor

  48. Medications: Short actingRescue • Anticholinergics, MDI or nebulizer (Atrovent) • Short acting • Rescue • Costs • Adverse effects rare, dryness

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