1 / 25

Tutor Guide

Tutor Guide. Health problems. Definition. chronic bronchitis defined as excessive cough and sputum production on most days for at least 3 months per year during at least 2 consecutive years

osman
Download Presentation

Tutor Guide

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Tutor Guide Health problems

  2. Definition • chronic bronchitis defined as excessive cough and sputum production on most days for at least 3 months per year during at least 2 consecutive years • emphysema defined as abnormal, permanent enlargement of air spaces distal to terminal bronchioles, accompanied by destruction of their walls

  3. Types • COPD severity staging based on post-bronchodilator forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC)COPD Severity Staging • Stage I - mild FEV1/FVC < 0.7 FEV1 ≥ 80% predicted • Stage II - moderate FEV1/FVC < 0.7 FEV1 ≥ 50% and < 80% predicted • Stage III - severe FEV1/FVC < 0.7 FEV1 ≥ 30% and < 50% predicted • Stage IV - very severe FEV1/FVC < 0.7 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure • Abbreviations: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity. • Reference - Global Initiative for Chronic Obstructive Lung Disease (GOLD) global strategy for diagnosis, management and prevention of COPD can be found at National Guideline Clearinghouse 2009 Jun 1:14175 or at GOLD, summary of previous version can be found in Am J Respir Crit Care Med 2007 Sep 15;176(6):532

  4. Incidence and prevalence • incidence/Prevalence: about 20% adult Americans (10-15 million people) affected • estimated 4% to 10% prevalence of COPD worldwide • Reference - Chest 2003 May;123(5):1684  EBSCOhost Full Text full-text in Bandolier 2003 Aug;113:3

  5. Causes and Pathogenesis Causes: • chronic irritation by inhaled substances, usually cigarette smoking • emphysema rarely caused by alpha-1 antitrypsin (AAT) deficiency Pathogenesis: • mucus gland hyperplasia in chronic bronchitis • destruction of elastic tissue of alveolar membranes, distention of air spaces, "air trapping" in emphysema COPD progression associated with small airway changes with accumulation of inflammatory mucous exudate in lumen and inflammatory infiltrate (including lymphoid follicles) in wall, based on histological evaluation of surgical specimens from 159 patients (N Engl J Med 2004 Jun 24;350(26):2645)

  6. Risk factors • Organs Involved: lungs, bronchi, bronchioles, alveolar ducts larger airways for chronic bronchitis, lungs distal to terminal bronchioles for emphysema mild form of emphysema found in normal persons > 50 years old in apices of lung • Who is most affected: almost exclusively in smokers • advancing age (peak onset 40-44 years for chronic bronchitis, 50-75 years for emphysema) • men (because of demographic trends in smoking habits, not specifically related to gender)

  7. Possible Risk factors • elevated inflammation-sensitive plasma proteins (ISPs) associated with increased incidence of hospital admissions for COPD in initially healthy men followed for 25 years • superoxide dismutase 3 (SOD3) gene polymorphisms associated with increased risk for COPD hospitalization and COPD mortality • western pattern diet appears associated with risk of COPD • Acetaminophen use associated with asthma and COPD diagnosis • marijuana and tobacco use may be associated with increased risk of pulmonary symptoms and COPD • long-term marijuana smoking associated with increased respiratory symptoms including cough, phlegm and wheeze • higher cumulative lifetime home and work exposure to environmental tobacco smoke associated with increased risk of COPD • exposure to passive smoking at home and work associated with COPD and respiratory symptoms

  8. Complications • Complications • pulmonary hypertension (hypoxia-induced vasoconstriction) • corpulmonale (right heart failure), edema • frequent infections (H. influenzae and S. pneumoniae be related to acute exacerbations) • Polycythemia • respiratory failure, • nocturnal hypoxia • general disability • proclivity for peptic ulcer disease • osteoporosis detected in 30-40% of 87 male COPD patients • moderate to severe obstructive lung disease (FEV1 < 80% predicted and FEV1/FVC ratio < 70%) associated with 2.8-fold risk of incident lung cancer

  9. Hx • Chief Concern (CC): productive cough dyspnea, may be episodic or progressive • History of Present Illness (HPI): chronic bronchitis defined as productive cough on most days for > 3 months/year for at least 2 years sputum production may be considerable early in disease if decompensation consider infection, bronchospasm, pneumothorax, pulmonary embolism, acute myocardial infarction, corpulmonale, anxiety) • symptoms worse in cold air; tests in lung function laboratory on 18 patients with COPD showed that severe cold reduced maximum workload and shortened time for which patients could continue vigorous exercise

  10. Sx pattern with Emphysema • severe early dyspnea • little or no cough • Wheezing • late cough with scanty sputum • weight loss • history of previous episodes of dyspnea • expectoration (with concomitant chronic bronchitis)

  11. Social Hx • Smoking • coal miners

  12. Physical • end-stage findings - edema, cyanosis, plethora, increased work of breathing, physical appearance with emphysema: • thin, barrel chest, cachecticappearance dyspneamanifest by pursed-lip breathing and use of accessory muscles

  13. Physical Lungs • Lungs: • Rhonchi • Wheezes • Coarse rales • Decreased breath sounds • Hyperinflation • http://www.stethographics.com/main/physiology_ls_introduction.html

  14. R/O DDx • Cardiac disease • Right heart failure • Asthma • respiratory acidosis • interstitial lung disease • Anemia • consider central sleep apnea if FEV1 > 1 L and carbon dioxide retention

  15. Blood tests • Blood tests: • arterial blood gas (ABG) shows increased PCO2, decreased PO2 (if severe), and low pH in acute phase with chronic bronchitis • ABG may be normal, mild hypoxia, hypocapnia with emphysema, low PO2, normal or high PCO2 • polycythemia, CBC may show increased WBC count with left shift and erythrocytosis

  16. Imaging Studies Chronic bronchitis chest x-ray findings: • normal or peribronchialthickening prominent vessels (large pulmonary artery if pulmonary hypertension) cardiomegaly, normal level of diaphragms (hyperinflation if emphysematous component) marked V/Q mismatch on ventilation perfusion scan Emphysema chest x-ray findings • increased AP diameter, increased retrosternal air space, flattened diaphragms, hyperinflation, small heart decreased vascular markings

  17. ECG ECG may show right axis deviation, right bundle branch block, vertical P wave axis (inverted P wave in aVL), supraventricular rhythm disturbances (e.g. multifocal atrial tachycardia, atrial fibrillation, atrial flutter)

  18. Pathology • findings on airway biopsy include goblet cell hyperplasia, mucosal and submucosal inflammation, and increased smooth muscle at the level of small noncartilaginousairways • Reid index is a quantitative approach to describing these pathologic findings

  19. Prognosis • number of deaths from COPD in United States • 121,267 in 2003 (64.3 per 100,000 population ≥ 25 years old) • 117,134 in 2004 (61.1 per 100,000 population ≥ 25 years old) • 126,005 in 2005 (64.3 per 100,000 population ≥ 25 years old)

  20. Bode index • based on derivation and validation cohorts BODE index ranges 0-10 points • Body mass index - 0 points if > 21 kg/m2, 1 point if ≤ 21 kg/m2 • Obstruction - 0 points if FEV1 ≥ 65% predicted, 1 point if FEV1 50-64% predicted, 2 points if 36-49% predicted, 3 points if ≤ 35% predicted • Dyspnea- score 0-3 with 3 points if too breathless to leave home or breathless when dressing or undressing • Exercise capacity (six-minute walk test) - 0 points if ≥ 350 meters, 1 point if 250-349 meters, 2 points if 150-249 meters, 3 points if ≤ 149 meters

  21. ADO index • ADO index ranges 0-10 points • Age - 0 points if 40-49 years, 1 point if 50-59 years, 2 points if 60-69 years, 3 points if 70-79 years, 4 points if 80-89 years, 5 points if ≥ 90 years • Dyspnea- score 0-3 with 3 points if too breathless to leave home or breathless when dressing or undressing • Obstruction - 0 points if FEV1 ≥ 65% predicted, 1 point if FEV1 36-64% predicted, 2 points if FEV1 ≤ 35% predicted

  22. ADO index Score Mortality in Patients with Mortality after the first Long-standing and Severe COPD hospital admission for COPD • 0 7.2% 3% • 1 9.9% 4% • 2 13.5% 5.4% • 3 18.1% 7.3% • 4 23.9% 9.8% • 5 30.8% 12.9% • 6 38.7% 16.9% • 7 47.2% 21.8% • 8 55.9% 27.6% • 9 64.2% 34.3% • 10 71.8% 41.7%

  23. Tx • smoking cessation in early COPD reduces respiratory symptoms and improves quality of life, based on large randomized trial • bupropioneffective for smoking cessation in COPD patients (NNT 7 at 7 weeks, NNT 14 at 26 weeks), based on randomized trial • ensure adequate education regarding role of medications (routine use vs. as-needed use) inhaler techniques • pretreatment prior to activity American College of Physicians guideline on diagnosis and management of stable chronic obstructive pulmonary disease • reserve treatment for patients with respiratory symptoms and FEV1 < 60% predicted • prescribe 1 of the following maintenance monotherapies: long-acting inhaled beta-agonist, long-acting inhaled anticholinergic, inhaled corticosteroid • consider combination inhaled therapies • prescribe oxygen if resting hypoxemia (PaO2 ≤ 55 mm Hg) • consider pulmonary rehabilitation in symptomatic patients with FEV1 < 50% predicted

  24. Diet excercise • omega-3 supplement might reduce risk of acute COPD exacerbation • nutritional support (caloric supplementation for at least 2 weeks) has not demonstrated any significant effect on anthropometric measures, lung function or exercise capacity in patients with stable COPD • regular physical activity associated with lower incidence of hospital admission for COPD and mortality • upper extremity exercise training associated with improved functional capacity • pedometer-based exercise counseling program associated with improved strength and greater activity level in patients with COPD • maximally intense endurance program associated with symptomatic improvement • pulmonary rehabilitation program including regular exercise associated with improved exercise capacity and reduced exertionaldyspnea • pulmonary rehabilitation might improve walking performance • interval exercise and high-intensity continuous exercise associated with similar large improvements in health-related quality of life • yoga program may improve walking performance and self-reported function in patients with COPD

  25. Surgical Tx Lung-volume reduction surgery (LVRS): • patients who survive ≥ 3 months post-LVRS may have better health status and lung function compared to usual medical care • LVRS may increase exercise capacity in some patients • LVRS may improve quality of life for selected patients but mortality risk unclear Lung transplantation: • lung transplantation may not improve survival in patients with end-stage emphysema • bilateral lung transplantation may be associated with increased survival compared to single lung transplant in patients with COPD

More Related