Pulmonary Predicaments in Primary Care Peter F. Bidey, DO

Pulmonary Predicaments in Primary Care Peter F. Bidey, DO

Pulmonary Predicaments in Primary Care Peter F. Bidey, D.O. Clinical Instructor -Family Medicine Philadelphia College of Osteopathic Medicine ACOFP Intensive Update and Board Review August 22, 2015 Chicago, IL Objectives Examine and differentiate asthma and COPD diagnosis and treatments Review diagnosis and treatment of pulmonary tuberculosis in out-patient setting Review diagnosis and treatment of community acquired pneumonia in out-patient setting Case A 45 year old male presents to your office complaining of wheeze and DOE over the past year. Patient states he remembers having some issues with asthma as a child but no issues for many years. He reports a 10 pack year history of tobacco use and quit smoking 15 years ago. He states his mother has COPD and his father has asthma. 1

Case Asthma or COPD? How would management change? Thorax 2008;63:761-767 doi:10.1136/thx.2007.089193 Asthma Definition Chronic disorder with recurring symptoms of airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation It is a reversible obstructive lung disease Symptoms Wheeze Cough Shortness of breath Chest tightness Asthma Diagnosis History Episodic and trigger-induced wheeze, SOB, DOE, and cough Family History and/or personal history as child Physical Exam Wheeze Atopic dermatitis and allergic rhinitis Viscerosomatic reflexes, diaphragmatic disorders, and rib dysfunctions 2

Asthma Diagnosis cont. Studies Spirometry Pre-and Post-bronchodilator Methacholine Challenge Good for patients with normal baseline airflow Peak Expiratory Flow Meter Better for monitoring known disease Labs Chest radiograph Differential Diagnosis Children Allergic rhinitis Recurrent bronchitis Vocal chord dysfunction GERD Recurrent aspiration Laryngotracheomalacia Bronchiolitis Cystic fibrosis Panic disorder Adults Rhinosinusitits COPD Vocal chord dysfunction CHF GERD PE Tumor Drug induced cough Sarcoidosis Asthma Classification Mild Intermittent Mild Persistent Symptoms 2days/week >2 days/week but not daily Rescue inhaler Use Nighttime awaking Interference with activity Lung function 2days/week >2days/week but not daily Moderate Persistent Daily Daily 2x/month 3-4x/month >1x/week but not nightly Severe Persistent Throughout day Several times /day Often 7x/week None Minor Some Very limited FEV1>80% predicted FEV1/FVC normal FEV1>80% predicted FEV1/FVC normal FEV1>60% but <80% predicted FEV1/FVC reduced 5% FEV1<60% predicted FEV1/FVC reduced >5% 3

Chronic Obstructive Pulmonary Disease Definition Airflow limitation that is progressive and associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles and gases Includes sub-types: emphysema, chronic bronchitis, and chronic obstructive asthma 210 million diagnosed worldwide and by 2030 will be 3 rd most common cause of death in the world Symptoms Chronic progressive-cough, sputum production, and dyspnea COPD Diagnosis History Smoking and inhalation exposure Progressive DOE, chronic cough, and increase in sputum production Physical Exam Early disease is usually normal Hyperinflation, decreased breath sounds, wheezes, decreased heart sounds, and crackles at bases Severe disease results in barrel chest, flattening of the diaphragm, and pursed lip breathing COPD Diagnosis cont. Studies Spirometry FEV1/FVC < 0.70 or 5% lower limit of normal(lln) Post-bronchodilator Chest radiograph vs. CT scan Lab tests Can consider: ABG-FEV1 <50% predicted or pulse ox <92% CBC/CMP α-1 antitrypsin 4

Spirometry Results http://www.thinkcopdifferently.com/en/about-copd/diagnosing-copd/spirometric-assessment Differential Diagnosis Asthma Tumor Heart failure Bronchiectasis Tuberculosis Sleep apnea Restrictive lung disease Interstitial lung disease GOLD Criteria Classification of Severity Global Initiative for Chronic Obstructive Lung Disease All have FEV1/FVC<0.7 or <5%LLN of FEV1/FVC GOLD 1-Mild FEV1 80% predicted GOLD 2-Moderate GOLD 3-Severe GOLD 4-Very Severe FEV1 50% predicted and <80% predicted FEV1 30% predicted and <50% predicted FEV1<30% predicted 5

GOLD Disease Category Combines FEV1 level with symptoms and history of exaggerations Individual symptoms Uses modified Medical Research Council (mmrc) or COPD or COPD assessment test (CAT) Number of exacerbations in 12 months Combined Assessment of COPD Tashkin & FergusonRespiratory Research. 2013;14(49) 2013 BioMedCentral, Ltd. http://www.medscape.com/viewarticle/808544_2 - Accessed July 7, 2015 Case A 45 year old male presents to your office complaining of wheeze and DOE over the past year. Patient states he remembers having some issues with asthma as a child but no issues for many years. He reports a 10 pack year history of tobacco use and quit smoking 15 years ago. He states his mother has COPD and his father has asthma. Asthma or COPD? Still undecided? 6

Asthma Treatment Goal Daytime symptoms <2x/week and nighttime symptoms <2x month Avoid triggers Vaccines Influenza and Pneumococcal recommendations Stepwise treatment fashion Rescue inhaler use with short-acting β-2 agonists (SABA) Acute exaggerations usually require systemic steroids Asthma action plan Mild Intermittent Asthma No controller medication needed SABA PRN Albuterol MDI with spacer as effective as nebulized solution as well as more cost effective Mild Persistent Asthma Maintenance medication using low-dose inhaled corticosteroids (ICS) Can consider asthma action plan Can consider leukotriene receptor antagonists 7

Moderate Persistent Asthma Maintenance medications using low-dose ICS with: Long-acting β-2 agonists (LABA) Leukotriene modifiers Cromolyn OR Maintenance medication using medium-dose ICS Severe Persistent Asthma Maintenance medications using high-dose ICS and LABAs Can consider all other add-ons including theophylline and immunotherapy Can consider oral corticosteroids but want to limit long term use Exercise-Induced Asthma Symptoms similar to asthma but usually only associated with exercise Treat with SABA 10 minutes prior to exercise Minimize irritant exposure and can consider leukotriene modifiers 8

Asthma Treatment Summary National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health, National Heart, Lung, and Blood Institute. August 2007. NIH publication 08-4051. COPD Treatment-Stable Patients STOP smoking or exposure to other irritants Step-wise treatment fashion Pulmonary Rehabilitation Vaccines Influenza Pneumococcal Oxygen therapy for patient with severe hypoxemia COPD Treatment Patient Group A B C First Choice Second Choice Alternatives Short-acting anticholinergic PRN or SABA PRN Long acting anticholinergic or LABA ICS & LABA or Longacting anticholinergic LAMA or LABA or SABA & SAMA LAMA & LABA LAMA & LABA or LAMA & PDE 4 or LABA & PDE 4 Theophylline SAMA PRN &/0r SABA PRN Theophylline SAMA &/0r SABA Theophylline D ICS & LABA &/or Long-acting anticholinergic ICS & LABA & LAMA or ICS & LABA & PDE4 or LAMA & LABA or LAMA & PDE4 SAMA PRN &/0r SABA PRN Theophylline Carbocysteine 9

Acute COPD Exacerbations Systemic Steroids Bronchodilators Antibiotics BiPAP vs. mechanical ventilation Osteopathic Treatments Release the diaphragm Correct rib lesions Lymphatic pumps Rib raising Case A 27 year old female medical student presents to have TST read 48 hours after administration. She was exposed to a patient with confirmed active tuberculosis 8 weeks ago on her Emergency Medicine rotation. Initial TST was negative. Today, the induration measures 14 mm. She denies any systemic symptoms and is otherwise without complaints. She has no significant past medical history. A CXR was ordered and shows no abnormalities. She has no history of positive TST or previous BCG vaccination. Diagnosis and Treatment? 10

Pulmonary Tuberculosis-Latent History Testing should be performed in patients with recent contact and who are at high risk of conversion Diagnosis in HIV-negative patients Tuberculin Skin Test Preferred test for children <5 Interferon Gamma Release Assays Can be used in all settings in place of TST. Preferred test in BCG-vaccinated individuals Possible use for determining false positives Two-Step Testing Performed 1 to 4 weeks after initial testing in absence of exposure Pulmonary Tuberculosis-Latent Treatment Goal To avoid conversion to active tuberculosis Additional Tests Obtain CXR, HIV testing, pregnancy, and baseline LFTs Monitor for any signs of active tuberculosis Medications Isoniazid +/- pryidoxine for 9 months Can consider alternative treatments of INH with rifapentine for 3 months if recent exposure >12 years old Direct observation treatment Interpretation of Tuberculin Skin Test 5mm HIV infection, close contact of active contagious case, Abnormal CXR consistent with old TB, or immunosuppressed patients 10mm High risk of reactivation-silicosis, ESRD, DM, leukemia, lymphoma, head/neck/lung CA, underweight, jejunoileal bypass, IV-drug user Children <4 years of age Foreign born from countries with incidence >25/100000 Residents and employees in high risk settings 15mm Healthy persons with low likelihood of true TB infection 11

Case A 37 year old male social worker presents with recent 10lb weight loss over the past six months as well as fatigue. He states recently he has noticed some night sweats and has recently developed a cough. He works at a homeless shelter and states his boss asked him to come and get checked out. A CXR is ordered that shows an abnormality in the apical region of the right upper lobe. Diagnosis and Treatment? Pulmonary Tuberculosis-Active History Risks for exposure Fever, night sweats, cough, weight loss, fatigue, and hemoptysis Physical Exam Usually non-specific but include dullness of lung sounds or occasional rales Studies Baseline LFTs, kidney function, CBC, and uric acid HIV and hepatitis testing CXR Sputum culture with AFB testing Baseline visual acuity and red-green discrimination when using ethambutol Pulmonary Tuberculosis-Active Treatment Initial phase consists of 2 months with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) Continuation phase usually then continues with 4 months of isoniazid and rifampin Monitor for side effects 12

Pulmonary Tuberculosis-Active Initial Phase Continuation Phase Drugs Interval and doses Drugs Interval and doses INH RIF PZA EMB Seven days per week for 56 doses (8 weeks) or 5 days/week for 40 doses (8 weeks) INH/RIF 7 d/wk for 18 weeks or 5d/wk for 18 weeks INH/RIF Twice weekly for 18 weeks INH/RPT Once weekly for 18 weeks Cavitation on CXR & (+) sputum @ 2 months require 7 months continuation phase DOT HIV (-), negative sputum @2months, no cavitation on CXR Case A 56 year old diabetic female presents to your outpatient clinic with fever, chills, and cough which has worsened over the past week. She states she had an URI 2 months ago and was treated with Azithromycin and improved. Currently her vitals are- Temp: 101 F, RR-20, HR-101, BP-126/88, and PO-97%. Her physical exams revealed rhonchi in the left lower lobe. Otherwise exam is unremarkable. Diagnosis and Treatment? Community Acquired Pneumonia (CAP) History Fevers, chills, cough, dyspnea, pleuritic chest pain, sputum production Inquire about recent antibiotic use, hospitalizations, or other risks Physical Exam Increased respiratory rate, increased pulse, rales, or rhonchi Studies CXR Optional blood work and sputum/blood cultures (Outpatient) 13

Community Acquired Pneumonia (CAP) Treatment Admit or Not to Admit? CURB-65 Confusion (based upon a specific mental test or new disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/l (20 mg/dl) Respiratory rate >30 breaths/minute Blood pressure (systolic <90 mmhg or diastolic <60 mmhg) Age >65 years Community Acquired Pneumonia (CAP) Treatment Monitor for increased risk of drug resistant strains Age >65 years Recent ABX use in past 3 months Alcoholism Medical comorbidities Immunosuppressive illness or therapy Environmental exposures Community Acquired Pneumonia (CAP) Treatment No comorbidities or recent ABX use Macrolids or Doxycycline Doxycycline is preferred if concern of QT prolongation Treatment length is at least 5 days and 48 to 72 without fever Comorbidities or recent ABX use Respiratory fluoroquinolone OR beta-lactam effective against S. pneumoniae PLUS a macrolid or doxycycline Follow-up CXR Vaccination 14

Questions 15