Obstructive Pulmonary Disease - Clin Med 4

What does this refer to

• : amount of air that is inspired and expired during a normal breath

Tidal Volume (TV)

What does this refer to

• : additional amount of air that can be exhaled after a normal exhalation

Expiratory reserve volume (ERV)

What does this refer to

• : additional amount of air that can be inhaled after a normal inhalation

Inspiratory reserve volume (IRV)

What does this refer to

• : amount of air that is left after expiratory reserve volume is exhaled

Residual volume (RV)

What does this refer to

• : the amount of volume of air that has been exhaled at the end of the 1st second of forced expiration

Forced Expiratory Volume in 1 second (FEV1)

What does this refer to

• = ERV + TV + IRV

• Maximum amount of air that can be inhaled or exhaled during a respiratory cycle

Vital Capacity (VC)

What does this refer to

• = TV + IRV

• Amount of air that can be inhaled after the end of a normal expiration

Inspiratory Capacity (IC)

What does this refer to

• = ERV + RV

• Amount of additional air that can be exhaled after a normal expiration

Functional Residual Capacity (FRC)

What does this refer to

• = RV + ERV + TV + IRV

• Total amount of air the lung can hold

Total Lung Capacity (TLC)

What does this refer to

• amount of volume of air that can be expelled from maximally inflated lung with the patient breathing as hard and fast as possible

Forced Vital Capacity (FVC)

What does this refer to

• A pulmonary function test

  • Measures how well O2 moves from the lungs into the bloodstream

  • Involves breathing in a gas that contains a small amount of CO

    • Measuring how much of it passes into the blood

Diffusing Capacity for Carbon Monoxide (CO)

What is the top box

Chronic bronchitis

What is the bottom box

Emphysema

What does this refer to

chronic obstructive pulmonary disease (COPD)

What does this refer to

• COPD is the 3rd leading cause of death in the U.S.

• Most prevalent in smokers

• M > F (1 : 0.9)

• MC age dx 45

• Age 30 and older + smoking for at least 10 years significant increased risk

• Alpha-1 antitrypsin deficiency (AATD) is among the most prevalent potentially fatal genetic disorders in the U.S., and occurs approximately equally in men and women

EpidemiologyChronic Obstructive Pulmonary Disease (COPD)

What does this refer to

• A 59-year-old man presents to the emergency department with severe pleuritic chest pain.

• He is worried he might have another collapsed lung.

• VS – Temp 98.7°F (37.1°C), BP 118/78 mmHg, HR 119/min, RR 31/min, SaO2 85% RA.

• Exam: he appears cachectic.

• A chest radiograph is obtained.

• Document: level of distress, increased work of breathing, +/- use of accessory muscles

Emphysema

What does this refer to

Emphysema

What does this refer to

• Permanent enlargement of the terminal air spaces (distal to the terminal bronchioles)

• No evidence of obvious fibrosis

Emphysema

What does this refer to

• Smoking is the most common cause

  • Calculate pack years

    • # packs smoked per day x # years smoked

      • 1 pack per day x 20 years = 20 pack years

      • 2 packs per day x 20 years = 40 pack years

• Chronic inflammation and airspace enlargement

• Decreased protective enzymes (alpha-1 antitrypsin)

• Destruction of the alveolar walls and capillaries

• Loss of elasticity and recoil + airway collapse + airway obstruction

EtiologyEmphysema

What type of emphysema does this refer to

• Emphysema is defined by alveolar wall destruction and dilation that presents in 2 forms

  • Centrilobular

    • Almost always due to smoking

• Panlobular/panacinar

  • Rare and caused by alpha-1-antitrypsin deficiency

Main types of Emphysema

What does this refer to

• Combined pulmonary fibrosis and emphysema (CPFE)

• Interstitial emphysema

• Bullous emphysema

• Senile emphysema

• Irregular emphysema

Minor Types of Emphysema

What does this refer to

• Centriacinar (Centrilobular) emphysema

  • Upper lobe predominant

  • Respiratory bronchioles and surrounding lung parenchyma

• Panacinar emphysema

  • Lower lobe predominant

  • Entire acinus

• Paraseptal emphysema

  • Upper lung

  • Distal part of acinus in subpleural area

Emphysema sites

What does this refer to

• Dyspnea (hallmark)

• Mild cough (initially) —> chronic cough (initially non-productive MC) —> sputum

• Chest inflation/hyperventilation

• Fatigue

Clinical historyEmphysema

What does this refer to

• Decreased breath sounds

• Hyperresonance to percussion

• Increased AP diameter

• Accessory muscle use

• Tachypnea

• Hypoxia/hypoxemia

• Barrel chest

• Semi-tripod position

• Pursed lip breathing

• Breath sounds

  • End expiratory wheeze/prolonged expiration

• “Pink Puffers”

  • Non-cyanotic

  • Cachectic

  • Pursed lip breathing

Emphysema Physical Exam

What does this refer to

• Chronic bronchitis v Emphysema v Asthma

• Interstitial lung disease (restrictive pattern)

• Respiratory tract infection

• Alpha 1-Antitrypsin (AAT) deficiency

• Heart Failure

• Bronchiectasis

• Chronic cough

• Pulmonary embolism

Differential diagnosisEmphysema

What does this refer to

• Pulmonary Function Test (PFT) GOLD Std

• Pulse oximetry

• Arterial Blood Gas (ABG) SaO2 < 92% (AMS or Acute exacerbation)  PO2

• CBC w/ diff ( Hgb)

• CMP

• Sputum evaluation

• Alpha1-Antitrypsin (when?)

• B-type natriuretic peptide or Pro-BNP (when)?

• Cardiac biomarkers (?) + EKG (?)

Work up for Emphysema

What does this refer to

Emphysema

What does this refer to

• Arterial Blood Gas (ABG) SaO2 < 92% (AMS or Acute exacerbation)

• ↓ PO2

• ↑ Hgb

• ↑RBC

Lab Results of Emphysema (Work up)

What does this refer to

Emphysema

• Flat diaphragm

• ↑ AP diameter

• Decreased vascular markings

• Visible bullae

What does this refer to

• 6 minute walking test

• V/Q scan (ventilation and perfusion)

  • Matched defects

  • Mild to moderate hypoxemia

  • CO2 often normal in early disease

• CT chest with IV contrast

• 2D echocardiogram

Additional Workup Emphysema

What does this refer to

• Best initial test

• Obstructive pattern

  • Decreased FEV1

    • Mild: > 80%

    • Moderate: 50-79%

    • Severe: 30-49%

    • Very severe: < 30%

• Decreased FEV1/FVC <70% predicted

• Decreased FVC

Pulmonary Function Test for Emphysema

What does this refer to

• Obstructive pattern on PFT that is not fully reversible

  • Decreased FEV1

  • Decreased FEV1/FVC < 70% of predicted

  • Decreased FVC

  • Hyperinflation

  • Decreased DLCO (how easily carbon monoxide (CO) molecules transfer from the alveolar gas to the hemoglobin of the red cells in the pulmonary circulation)

• CXR – hyperinflation with flattened diaphragms, increased AP diameter decreased vascular markings and bullae

• ABG – can develop respiratory acidosis if severe

How is Emphysema diagnosed

What does this refer to

• Step 1 – spirometry/PFT

  • FEV1/FVC < 0.7 (70%)

• Step 2 – administer SABA

  • Repeat spirometry/PFT

    • FEV1/FVC does not improve after SABA

• Step 3

  • Based on measured values – assigned GOLD category 1, 2, 3, or 4

• Step 4

  • Administer COPD Assessment Test (CAT) and COPD Control Questionnaire (CCQ)

• Step 5

  • Analyze the exacerbation history (low or high risk of exacerbation = hospitalizations

• Step 6

  • Refined ABCED Assessment Tool

How Emphysema is diagnosed

What does this refer to

Step 6 – Refined ABCD Assessment Tool(Emphysema)

What physical exam finding would cause you to order a BNP

Edema (bc you are concerned with heart failure)

What does this refer to

ClassificationSymptom and Severity Risk of Emphysema

What does this refer to

• Consult/referral Pulmonology

• 1st line – SMOKING CESSATION then

• Home O2 if resting PaO2 < 55mmHg or SaO2 RA < 89%

• Preventive Care

  • Vaccinations

    • Influenza

    • Pneumonia

    • COVID

• Good patient education

• Establish self-treatment plans for exacerbations

• Early diagnosis and aggressive management of infections

Clinical Management of Emphysema

What does this refer to

• Cor pulmonale

• SaO2 saturation < 88% on RA

• PaO2 < 55mmHg on RA

• Long-term use of O2 reduces mortality and improves quality of life in severe COPD

Clinical interventionsIndication for Oxygen Therapy

Emphysema is related to

Respiratory acidosis

What does this refer to

• _______________ mark the end of the conducting zone of the respiratory system, solely responsible for air transport.

Terminal bronchioles

What does this refer to

• ____________ are the beginning of the respiratory zone, where gas exchange (oxygen and carbon dioxide) begins to occur.

Respiratory bronchioles

What does this refer to

Clinical intervention Supplemental O2

What does this refer to

Bronchodilators

• Long-acting beta2 agonists (LABA)

• Long-acting muscarinic antagonists (LAMA)

• Short-acting beta agonist (SABA)

• Short-acting muscarinic antagonist (SAMA)

Other

• Long-acting anticholinergics (LAAC)

• Inhaled corticosteroids

• Combination MDI

Clinical management Metered-Dose Inhalers (MDI)

Do you use steroids earlier or later in COPD

Later

Do you use steroids earlier or later in asthma

Earlier

What does the top box refer to

Short-Acting Beta Agonists (4-6 h)

What does the second refer to

Long-acting beta-agonists (12 h)

What does the third box refer to

Approved Ultralong-Acting Beta Agonists (24 h)

What does this refer to

LAMA inhalers for COPD

What does this refer to

• Fluticasone (Flovent HFA)

• Budesonide (Pulmicort Flexhaler)

• Mometasone (Asmanex Twisthaler)

• Beclomethasone (Qvar RediHaler)

• Ciclesonide (Alvesco)

Inhaled corticosteroids (ICS)Obstructive Lung Disease

What does this refer to

look at it (slide 48)

What does this refer to

• Maintenance or acute exacerbations

• “Breathing treatment”

  • Requires DME nebulizer equipment

• Levalbuterol (Xopenex)

• Albuterol Sulfate + Ipratropium bromide (DuoNeb)

• Other inhaled (INH) meds may also have ICS

Clinical managementNebulized Medications

What does this refer to

DME Nebulizer

What is the initial pharmacological treatment for group A

A bronchodilator

What is the initial pharmacological treatment for group B

A long acting bronchodilator (LABA or LAMA)

What is the initial pharmacological treatment for group E

LAMA + LABA consider LABA + LAMA + ICS if blood eos > 300

What does this refer to

• SABA + SAMA rather than monotherapy

• Patients with persistent sx and exacerbations with LAMA/LABA combination

  • Escalated to LABA/LAMA/ICS

    • fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta) MDI daily

• Fluticasone furoate with vilanterol (Breo Ellipta)

• Budesonide INH/Formoterol/Glycopyrrolate INH (Breztri)

New(er) tx options Persistent Sx or Exacerbations

What does this refer to

• Beneficiary name or Medicare Beneficiary Identifier (MBI) Number.

• Description of the item.

• Quantity, if applicable.

• Treating practitioner name or National Provider Identifier (NPI)

• Date of the order.

• Treating practitioner signature.

Write the prescription for DME

What does this refer to

• Jane Doe

• Nebulizer unit

• Dispense one (1)

• ICD-10 code

• NPI #

• Date 07/08/2023

• Kimberly J. Rose, PA-C

Nebulizer DME Rx

What does this refer to

Manifestation of COPD Exacerbation

What does this refer to

Clinical PharmacotherapeuticsCOPD Exacerbations

What does this refer to

• A 46-year-old female presents to her primary care provider for follow-up for a severe, unrelenting, productive cough that she has had on and off for more than 2 years.

• She also complains of worsening dyspnea on exertion.

• She has smoked 1 pack per day since she was 18.

• A chest radiograph is obtained.

Chronic bronchitis

What does this refer to

• Inflammation (swelling) and irritation of the bronchial tubes

• Persistent airflow limitation due to small airway disease and parenchymal destruction

• To be defined as “Chronic”

  • Productive cough x 3 months in each of 2 successive years in a patient in whom other causes (such as bronchiectasis) have been excluded

Chronic Bronchitis

What does this refer to

• COPD is 3rd leading cause of death in the U.S. (4th worldwide)

• Most prevalent in smokers

• M > F

• Age 30 and older + smoking for at least 10 years significant increased risk

• Risk Factors

  • Tobacco use

  • Air pollution

  • Occupational exposure

  • Cystic fibrosis

Epidemiology of Chronic Bronchitis

What does this refer to

• Primary pathologic changes of chronic obstructive pulmonary disease (COPD) are found in the airways

• Changes are also seen in the lung parenchyma and pulmonary vasculature.

EtiologyChronic Bronchitis

Normal is on the left, what is the right showing

chronic bronchitis

What does this refer to

• Chronic inflammation

• Increased numbers of goblet cells

• Mucus gland hyperplasia

• Fibrosis

• Narrowing and reduction in the number of small airways

• Airway collapse due to the loss of tethering caused by alveolar wall destruction in emphysema.

Airway PathologyChronic Bronchitis

What does this refer to

• Chronic cough

  • Productive

  • Worse in morning

• Sputum production

• Dyspnea/DOE

Clinical history of chronic bronchitis

What does this refer to

Physical examChronic Bronchitis

What does this refer to

• ______ v Emphysema v Asthma

• Bronchiectasis – dx with CT

• Respiratory tract infection

• Alpha 1-Antitrypsin (AAT) deficiency

• Heart Failure

• Chronic cough

• Pulmonary embolism

Differential diagnosisChronic Bronchitis

What does this refer to

Workup Chronic Bronchitis

What does this refer to

PFT - Best Initial Test Chronic Bronchitis

What does this refer to

Chronic bronchitis

What does this refer to

• 6 minute walking test
  V/Q scan

• CT chest with IV contrast

• 2D echocardiogram

Additional Workup Chronic Bronchitis

What does this refer to

• Obstructive pattern on PFT that is not fully reversible

  • Decreased FEV1

  • Decreased FEV1/FVC < 70% of predicted

  • Decreased FVC

  • Hyperinflation

  • Normal DLCO (how easily carbon monoxide (CO) molecules transfer from the alveolar gas to the hemoglobin of the red cells in the pulmonary circulation)

• CXR – pulmonary HTN

• EKG – Cor pulmonale

• CBC w/ diff

  • Increased Hgb and HCT

• ABG – respiratory acidosis with hypercapnia

How’s it diagnosed?Chronic Bronchitis

What does this refer to

• Obstructive pattern

  • Decreased FEV1

  • Decreased FEV1/FVC < 70% of predicted

  • Decreased FVC

Pulmonary function test resultsChronic Bronchitis

What does this refer to

PrognosisChronic Obstructive Pulmonary Disease (COPD)

What does this refer to

Chronic Bronchitis

What does this refer to

Prognosis – 4 factors to determine the score on a point system (bode index)

What does the left box refer to

Emphysema

What does the right box refer to

Chronic bronchitis