COPD Diagnosis, Management and Program

Transcription

1 COPD Diagnosis, Management and Program RYAN MARTIN, MD NEBRASKA PULMONARY SPECIALTIES Initial diagnosis Setting matters: Inpatient. Usually sicker, oftentimes avoiding healthcare. Outpatient. Often seeking treatment before significant decompensation Symptoms Cough Sputum production Shortness of breath Cyanosis Hypoxia. Wheezing Clubbing

2 Diagnosis Setting matters Outpatient Symptom assessment CXR usually shows hyperinflation and more translucent lung fields, flattened diaphragm. PFTs Show obstructive pattern. Severity varies. DLCO may be altered. ABG May show either hypoxia, hypercapnia, both or neither Alternate diagnosis? Elevated total CO2 on BMP Polycythemia 1. Hyperinflation. 2. Hyperlucency 3. Increased retrocardiac airspace 4. Diaphragmatic flattening

3 Vs NORMAL. Diagnosis Inpatient. Usually arrive during acute exacerbation. Many of the above findings are present. Often times more prevalent even. Stage of disease is not determinate during the acute exacerbation ABGs are usually worse acutely. I avoid doing complete PFTs during acute exacerbation. Spiro or peak flow give enough information. Cyanosis and hypoxia may be initially present, often reverse with treatment. CXR findings are usually not appreciably different from acute to chronic settings

4 Obstructive PFTs. Above the X axis is EXPIRATION, below it is INSPIRATION Dotted line indicates the expected expiratory flow limb. COPD/Asthma will have the typical spike, but then the obstruction takes over Pursed lip breathing will move the obstruction to the more proximal part of the airway (Mouth) and help stent the smaller, distal airways open.

5 Reference ranges Very important to PFT interpretation Determinants are Age, Gender and Height. Ethnicity plays a smaller role ABG 7.40/40/90/24 is the normal ph / PCO2 / PO2 / Bicarb Numbers can change both acutely AND chronically. Look to the ph to help direct your acuity.

6 COPD It, at cellular level, is the destruction of the alveoli This includes loss of capillaries (where O2 and CO2 exchange occur) Predominantly caused by inhalation. Hyperinflation occurs due to loss of multiple alveoli As the lung becomes over-inflated, the airways become more collapsible. Forced expiration will exacerbate wheezing. GOLD 2017 Stages 1-4 derived by FEV1 Classes ABCD are combination based upon the : Stage + Symptoms. GOLD A is Stage 1 or 2 without exacerbations GOLD B is Stage 1 or 2 WITH exacerbation GOLD C is Stage 3 or 4 without exacerbations GOLD D is Stage 3 or 4 WITH exacerbations

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8 Treatment Mainstays of therapy are derived by severity Can be as simple as Albuterol alone/as needed. Most commonly people use 1-2 daily inhalers PLUS a rescue inhaler. Our practice uses the 2017 GOLD guidelines LAMA/LABA preferred medication (for initial start of medication) LAMA/LABA/ICS (for Frequent Exacerbations) PDE inhibitors (Daliresp and Theophylline) Antibiotics (occasionally in Severe patients) Steroids

9 New Data IMPACT trial GSK funded study that did a 3 arm trial Focused on the EXACERBATING patient. The arms are 1. Fluticasone/Vilanterol (LAMA/LABA class) 2. Umeclidinium/Vilanterol 3. Fluticasone/Umeclidinium/Vilanterol Results showing that in the multiple exacerbating patients, triple therapy was most successful PDE inhibitors Falls into the classification of Daliresp specifically. Major SE is the GI distress/upset. Typically lasts about 1 week New starter pack that uses smaller dose. Take a week off. Not suited for all COPD ers Typically the patients with Chronic Bronchitis

10 Acute Management of the Exacerbating Patient. Nebulized medicaitons available and routinely used include Brovana (Afomoterol) or Perforomist (Afomoterol) Pulmicort (Budesonide) Xopenex (Levalbuterol Duonebs (Ipratropium and Albuterol) Albuterol Atrovent (Ipratropium) Lonhala Acute Management of the Exacerbating Patient. Steroids Oral meds Prednisone IV meds Solu-Medrol (methylprednisolone) Antibiotics. Do not often require CAP or HCAP coverage.

11 Acute Management of the Exacerbating Patient. Antibiotics Selection depends on comorbid conditions Bronchiectasis Concurrent PNA Recent hospitalizations. Allergies Immune status GOLD guidelines update Transitioned to a LAMA/LABA for initial start of COPD GOLD 2 and 3 Bevespi, Anoro, Stiolto and Utibron LAMA/LABA/ICS reserved for the more severe categories GOLD 4, or c/d Trelegy Some Combination of LABA/ICS + LAMA

12 Device decisions Inhalers/MDI require typically about 30cc/sec to get medication delivery to the smaller airway where the mechanism of action can be achieved. Hand-eye coordination matters. MDI vs Elipta vs Respimat device. Activity level Extremely poor inspiratory capacity should dictate usage of NEBs. Program for Preventing Readmissions Centers around Transition of care from Acute to Chronic. Withdrawal of acute therapies to something that can be readily delivered at home. Devices such as Non-Invasive ventilation (BIPAP) can be life-saving in the hospital but may not always have a role as an outpatient. Nebulized therapy IV medications

13 Program for Preventing Readmissions Medication reconciliation is probably the single most important step Medication cost analysis Follow up appointment Home Health Care Durable medical equipment Pulmonary rehab Sleep disorders Program for Preventing Readmissions Constant self assessment. Routine analysis of data Iterative process to evaluate which steps are troublesome for patients Predictive analysis of our patient population. PNA, CHF, Aspiration and Hypercapnia predict readmission.

14 Oxygen Assessments Walking Oximetry is indicated when the DLCO drops below 55% predicted. 6MWT is better used in Prognostic implications High Altitude Simulation Testing can be done if patients concerned. Rule of thumb is if Dx of COPD/ILD and has exertional dyspnea, I would do one prior to significant elevation exposure >2 hours. Lung Cancer Screening Lung Cancer Screening Must be done at a screening center/registry Annual lung cancer screening CTs even if negative initial scan Simplest minimum requirements: 30 pack years Over the age 55, under the age of 80 Must have been a daily smoker within the last 15 years.

15 CT Lung Cancer Screening False positive rate may be as high as 97% New Fleischner Society guidelines for follow up of the pulmonary nodule Less concern for nodules < 6mm Ground glass lesions require longer follow up. Majority of the false positive tests simply end up as ongoing monitoring with LD CTs. Cases 82 yo male, retired farmer 55 pack years history, quit in 2009 Exertional dyspnea, Wheezing. CXR with hyperinflation, no evidence of nodule FEV1 58% predicted, FVC 89% predicted. No Sputum No weight loss Never hospitalized. Annual flu shot, has had Pneumovax.

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