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Asthma and COPD

Asthma and COPD. Elena Bissell MD Department of Family and Community Medicine. Objectives. Recognize symptoms/findings/pathology of Asthma Become familiar with asthma staging and treatment guidelines Recognize symptoms/risk factors/findings of COPD

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Asthma and COPD

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  1. Asthma and COPD Elena Bissell MD Department of Family and Community Medicine

  2. Objectives • Recognize symptoms/findings/pathology of Asthma • Become familiar with asthma staging and treatment guidelines • Recognize symptoms/risk factors/findings of COPD • Become familiar with COPD staging and treatment guidelines • Board Review Questions-get them ALL right

  3. Rosie Tucker is a 10 yo female who presents to clinic with increasing SOB and cough over the past few weeks. Her SOB and cough are worse at night. No fevers, chills or other pertinent ROS. Her mother has tried over the counter medicines for cough. Rosie says it is hard to breath and feels like she cannot “get air” when it happens. This has happened for a few years but is worse now.

  4. PMHx: Born preterm at 35 weeks, hx of RSV bronchiolitis requiring hospitalization at 5 months. No other PMHx other than previously mentioned. Social: Rosie’s family recently became homeless and are living in weekly rate motel on Central in SEH. No smokers in home.

  5. Vital signs HR 106, BP wnl for height and age, T 37, RR 30, Oxygen saturation 92% on RA She appears to be SOB but is otherwise well appearing. Not using accessory muscles for respiration, no nasal flaring. HEENT wnl, CV RRR no m,r,g, Pulm-mild inspiratory wheezes, no crackles, Abd soft nontender

  6. Infection-bronchiolitis, PNA, etc RAD-Asthma, chronic bronchitis Allergies-allergic rhinitis, pet, smoke Anxiety

  7. Characterized by airway obstruction that is reversible, airway inflammation and airway hyper-reactivity • Mediated by Eosinophils • Affected by Mast Cells along airway epithelium • Most is IgE mediated • Reversible with therapy (Beta agonist Albuterol)

  8. Asthma is a disease that disproportionally occurs among low-income individuals and tends to strike children who live in substandard housing. • There are many triggers for asthma, including dust mites, pollution, cockroaches, mold, pets, and tobacco smoke. • Asthma incidence is important in health assessment because it may be a proxy for exposure to second hand smoke in multi-unit housing. • Second hand tobacco smoke can contribute to asthma in multi-unit housing because as much as 65% of the air can be exchanged between housing units through ventilation, cracks and plumbing.

  9. This map indicates asthma hospitalizations in Bernalillo County from 2006-2010, with 40% of hospitalizations occurringamong children age 1 to 14. The map area representing the greatest number of asthma hospitalizations with the largest number of multi-unit housing parcels (and one of the county’s most impoverished areas)is the International District.

  10. Symptoms of cough, SOB, chest tightness, wheezing occur most at night/am or with triggers. ASK: When do symptoms occur? What triggers symptoms? Work environment? Chemicals? Smoking history or exposure, living situation Pets in house Carpet in house Child in Daycare or cared for at home Family history of Asthma or Atopy

  11. Spirometry may be normal • Often see Airflow obstruction • FEV1/FVC ratio <70% • Reversible with bronchodilation • Improvement in FEV1 or FVC of 200mL and 12% from baseline

  12. Children 0-4-always use ICS and not LABA alone (associated with more exacerbations), Fluticasone low dose 176mcg 2 puffs BID, medium dose 176-352mcg 2 puffs BID, high dose 352mcg 2 puffs BID ICS in pregnancy-no LABA

  13. Inhaled Corticosteroids

  14. Other drugs: • ICS +LABA- Mometasone/formeterol(Dulera) Budesonide/Formeterol (Symbicort) Fluticasone/Salmeterol (Advair) • Leukotriene Modifiers-Montelukast (Singulair), Zafirlukast • Immunomodulators (Anti IgE)-Omalizumab • Cromolyn (Mast cell stabilizer) • Theophylline*monitor serum concentration

  15. Asthma Action Plans!!!!

  16. 1. FM is a 7 yo female with exercise induced asthma. She uses short acting beta agonist (albuterol) every day before exercise and also requiring it 1-2x week for SOB symptoms. She is not experiencing any nighttime symptoms and has not had any exacerbations in the past year. -How would you classify her asthma? - How would you suggest to manage her asthma? a-refer to pulmonology b-add a low dose inhaled corticosteroid c-add a long acting beta agonist d-no changes to current management

  17. Mild persistent asthma No changes to current management

  18. 2. DM is a 49 yo female with asthma who has had multiple hospital admissions and exacerbations in the past. She comes into clinic today because she is feeling increasingly short of breath every day and having nighttime symptoms almost every night despite the proper use of her inhalers. She is not having a current exacerbation. You review her med list: albuterol prn, medium dose inhaled corticosteroid BID, long acting beta agonist. -How would you classify her asthma? -How would you manage her asthma? a-oral steroids b-oral steroids and antibiotics c-increase inhaled steroids to high dose BID and leukotriene modifier d-decrease inhaled steroids to low dose BID and add cromolyn sulfate

  19. Severe persistent asthma • increase inhaled steroids to high dose BID and leukotriene modifier

  20. Which one of the following is a monoclonal anti-immunoglobulin E antibody that currently is approved for managing asthma? • Benralizumab • Mepolizumab • Omalizumab • Reslizumab

  21. omalizumab

  22. A 9 yo male uses a short-acting bronchodilator 3 x a week to control asthma symptoms. Lately he has been waking up about 2x a week due to coughing. Which of the following is most appropriate? • Inhaled medium-dose corticosteroids • Scheduled short-acting bronchodilator • Scheduled long-acting bronchodilator • Leukotriene inhibitor

  23. Inhaled medium dose corticosteroid

  24. Questions?

  25. Now on to COPD…. Mr. Charles Tucker is a 65 yo male who comes into clinic with complaints of SOB with walking and ADLS over the past 2 months and a chronic productive cough. What other questions do you want to ask?

  26. ROS: no orthopnea, no swelling of LE, no F/C/NS, no recent weight loss, no hemoptysis • PHMx: Hypertension well controlled on HCTZ 25mg. No surgeries • Social: Grandfather of Rosie Tucker, lives with his wife. 1ppd smoker for 50 years, occasional etoh, no drug use/no hx of IVDU

  27. Vitals: T 36.9, BP 135/82, HR 89, RR 18, O2sat 89% on RA Mr. Tucker is thin appearing, NAD HEENT wnl, CV RRR no m,r,g, no JVD, Lungs with decreased breath sounds throughout and expiratory wheezing in all fields-No crackles, Abdwnl, LE without edema

  28. Infection-bronchitis, PNA, etc Respiratory: COPD, chronic bronchitis, other lung disease (occupational exposures, etc) Cardiovascular: CHF, pulmonary HTN Malignancy

  29. 12.6 million US citizens affected • Women account for 63% of COPD cases • ~70% of COPD patients are younger than 65 • Genetic Predisposition • Exposure to Smoking • Only 15-25% of smokers develop COPD • Alpha-1-antitrypsin deficiency is most common genetic disorder associated with COPD • Airway obstruction • Mucus hypersecretion • Emphysema (disrupted alveolar attachements) • Mucosal and peribronchial fibrosis and inflammation • Respiratory Bronchiolitis is precursor • Alveolar macrophages • Proteases • Cytokine mediators

  30. Symptoms • Dyspnea • Cough with and without phlegm • Fatigue • Reduction in Activities of Daily Living • Dyspnea history • Onset of symptoms does not occur until FEV1 is down 50%

  31. FEV1/FVC ratio <70% Incomplete or no response to bronchodilator

  32. Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1 • Gold I: Mild FEV1/FVC < 0.70 • FEV1 > 80% predicted • Gold II: Moderate FEV1/FVC < 0.70 • 50% FEV1 < 80% predicted • Gold III: Severe FEV1/FVC < 0.70 • 30% FEV1 < 50% predicted • Gold IV: Very Severe FEV1/FVC < 0.70 • FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory * SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

  33. Combined Assessment of COPD

  34. Group A:SAMA or SABALAMA or LABA Group B:LAMA or LABALAMA and LABA Group C:ICS + LAMA or ICS+ LABALAMA and LABA Group D: ICS +LABA or ICS +LABA and LAMA

  35. Recommendations per GOLD Guidelines 2017Evidence A • Vaccinations-pneumonia and influenza • Tobacco cessation • Oxygen in severe hypoxemia (88% at rest) • Regular use of ICS increases risk of PNA especially in severe disease • Long term use of oral glucocorticoids has numerous side effects • Pulmonary Rehab improves dyspnea, health status and exercise tolerance in stable pts

  36. Recommendations per GOLD Guidelines 2017Evidence A • Bronchodilators (SAMA and SABA) improve symptoms and FEV1 * • LABA and LAMAs improved lung function, dyspnea and reduce exacerbations* *combo is more effective • ICS with LABA is more effective than individual components in improving lung fxn and reducing exacerbations • In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

  37. 3. MS is a 56 yo female who is on albuterol prn for SOB related to her COPD. She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday. She hates it because it makes her heart race. She is not having increased cough or sputum production. You do spirometry on her and compare it to previous-her FEV1 was previously 80% of predicted and is now 60% of predicted. -What stage of COPD does she have? -How should you manage her COPD? a. schedule for lung transplant b. stop albuterol and add a long acting anticholinergic once a day c. add inhaled corticosteroid BID d. oral steroids and antibiotics for exacerbation -What other recommendations should be given to pt to reduce mortality?

  38. 4. BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency. He is on continuous oxygen at 4L NC. His FEV1 is 13% of predicted. He is on a combination of inhaled corticosteroid and long-acting beta2 agonist. He continues to feel very SOB and requests additional txt for symptom relief. -What stage is his COPD -What can you add for symptom relief? a. add long acting anticholinergic b. oral steroids every day c. morphine for dyspnea d. change his medications to nebulizations for improved symptom relief

  39. Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD? • Cromolyn • Long acting muscarinic antagonists • Methylxanthines (theophylline) • Oral antihistamines

  40. B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

  41. Spirometry can be used to monitor disease progression in COPD patients. To be reliable, what minimum interval is recommended? • 3 months • 9 months • 12 months • 24 months

  42. c. 12 months

  43. A 47 yo male presents with SOB and cough. On PFT his FVC is <80% predicted, his FEV/FVC is 90% predicted and there is no improvement with bronchodilator. The diffusing capacity of lung for carbon monoxide (DCLO) is also low. Based on these results, which one of the following is most likely to be the cause of this patient’s problem? • Asthma • Bronchiectasis • COPD • Cystic fibrosis • Idiopathic pulmonary fibrosis

  44. e- idiopathic pulmonary fibrosis!!! Pt has restrictive pattern with low diffusing capacity. All other choices would be obstructive pattern

  45. Asthma-IV or PO steroids, nebulizers, no abx unless suspect PNA COPD: IV or PO steroids, nebulizers, abx for decreased failure of txt and improved mortality

  46. References • Lee H, Kim J, Tagmazyan K. Treatment of stable chronic obstructive pulmonary disease: the GOLD guidelines. Am Fam Physician. 2013 Nov 15;88(10):655-63, 663B-F. • Mintz M. Asthma update: Part II. Medical management. Am Fam Physician. 2004 Sep 15;70(6):1061-6. • Bernalillo County Health Assessment 2012, Dept. of Health. • Google images • GOLD guidelines 2018 • Asthma Care and Quick Reference US Dept of Health and Human Services

  47. Resident School Evaluation Form

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