Asthma/COPD in 30 minutes - PowerPoint Presentation

1. Asthma/COPD in 30 minutesEric L. Olson MD, MSc, FCCP

2. Definition of Asthma A disease characterized by the following:Airway obstruction that is reversibleAirway InflammationIncreased airway responsiveness to a variety of stimuli

3. * NIH NAEPP 2007 Asthma Guidelines EPR-3

4. Overview of Asthma Statistics23 million asthmatics in the United States and risingEvery year, asthmatics have2 million emergency room visits450,000 hospitalizations (average LOS 3.6 days)> 100,000 lost work/school daysApproximately 4000 deaths per year (1.1 per 100,000)> $20 billion in health care costs annuallyMortality of asthma more than doubled from 1979 to the mid-1990s – has recently plateaued and began to decline slightly

5. Asthma Patient DemographicsUS Population = 272.4 Million (US Census, 5/1/99);Asthma Patients = 5.5% Prevalence (ALA, 10/97)AgeScott Levin:PDDA, MAT 7/99Asthma Physician Market DynamicsStudy3/99-10/99Morbidity & MortalityWeekly Report1998National Center for Health Statistics 1982-1994Scott Levin:PDDA, MAT 7/99Age 18+ y 10 million 67%Age 0-17 y 5 million 33%Severe persistent16%Moderatepersistent31%Mildpersistent25%Mildintermittent28%17 million asthma patients2.2 million African American6.6% prevalence3.5 million Hispanic11.2% prevalence8.9 million Caucasian4.6% prevalenceAsthmaPatientsSeverityRaceGenderMen 42%Women 57%

6. PFT DiagnosisEvidence of airway obstruction FEV1/FVC is reduced below normal (less than 0.70)Acute reversibility of airflow obstruction Is tested by administering a quick-acting bronchodilator (eg, albuterol) with a chamber device or nebulizer, and repeating spirometry 10 to 15 minutes later.An increase in FEV1 of 12 percent or more, accompanied by an absolute increase in FEV1 of at least 200 mL, can be attributed to bronchodilator responsiveness with 95 percent certainty.

7. SeveritySx/day PF or FEV1Sx/night PF variabilityDaily MedsPreferredAlternativesStep IMild Intermittent< 2 days/week > 80%< 2 nights/month < 20%noneStep IIMild Persistent>2/week but < 1x/day > 80%> 2 nights/month 20-30%ICS (low dose)Cromolyn, leukotriene (-), nedocromil, theophyllineStep IIIModerate PersistentDaily >60% - <80%> 1 night/week > 30%ICS + long-acting b agonistIncrease ICS (medium dose), add leukotriene (-) or theophyllineStep IVSevere PersistentContinual < 60%Frequent > 30% High dose ICS + long-acting b agonistOS, add leukotriene (-) or theophyllineNational Asthma Education and Prevention Program (NAEPP 2002)Revised 2/2003

8. Risk Factors for DeathUpToDate 2015Near-fatal and fatal asthma exacerbations may occur in patients with mild, moderate, or severe asthma and the course may be either slow or rapid in onset

9. Acute Respiratory Failure2 to 4 percent of all patients hospitalized require invasive mechanical ventilationThe decision to initiate mechanical ventilation should be based on serial clinical evaluationsFactors to consider include: Degree of obstruction, degree of distress, clinical findings, gas exchange and response to treatmentHypercapnea alone is not an indication for intubation Role of noninvasive positive pressure ventilation (NIPPV) in acute asthma exacerbations remains undeterminedNIPPV may be reasonable in selected patients prior to intubation

10. Acute Respiratory FailurePre-oxygenation can be difficult. Dual therapy with HFNC and NRBM or BMV is optimal. BMV must be done cautiously to avoid hyperinflationStudies suggest that ketamine and propofol have bronchodilatory properties and thus are suitable induction agents for status asthmaticus. Ketamine may be preferable because it aids bronchodilation through both direct and indirect mechanisms and helps to maintain blood pressure.Neuromuscular blocking agents (eg, succinylcholine or rocuronium) are often used unless there is a contraindicationLarge endotracheal tubes are desirable in order to minimize airway resistance and facilitate aggressive pulmonary toilet Opiate medications should be avoided due to the risk of histamine release exacerbating bronchoconstriction

11. Acute Respiratory FailureInitial ventilator settings are generally volume controlled.RR from 10 to 12 breaths/min, low tidal volumes 5-8 mL/kg, inspiratory flow up to 80 L/min. Positive end-expiratory pressure (PEEP) is usually initiated at 2-5 cm H2O. Dynamic hyperinflation is a common problem creates intrinsic PEEP (auto-PEEP) and elevates the plateau pressure (Pplat), which place the patient at risk for cardiovascular collapse, barotrauma, and increased work of breathing.Measurement of Pplat is performed during a brief breath-hold at end-inspiration. Intrinsic PEEP is calculated by subtracting any extrinsic (ventilator) PEEP from Pplat.

12. Acute Respiratory FailureAlternative therapiesanesthetic agents (eg, intravenous ketamine, inhaled halothane, isoflurane, enflurane, sevoflurane) have bronchodilating effectsHelium-oxygen (heliox) mixtures have been administered in an attempt to decrease the work of breathing and improve ventilation. parenteral beta-agonists are generally avoided except when concern for anaphylaxis or standard therapy has failed.Leukotriene receptor antagonists are an established therapy for chronic asthma, but the role of these medications in acute setting is unclear except in patients whose exacerbation was triggered by ingestion of aspirin or a nonsteroidal anti-inflammatory drug (NSAID).

13. COPD

14. COPDCharacterized by airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients – GOLD definitionSymptoms include: Dyspnea, chronic cough, chronic sputum productionExacerbations are frequentSpirometry required for diagnosis. FEV1/FVC < 0.70Third-ranked cause of death in the United States, killing more than 120,000 individuals annually

15. COPD StatisticsIn 2010, COPD resulted in $49.9 billion in direct and indirect costs . Total costs incurred by COPD patients are approximately $6000 higher than non-COPD patients. 13-14% of COPD patients had a hospital readmission; 41-49% had a readmission within 60 days. The average direct per patient costs for commercially insured increased 6% per year between 2006 and 2009.Treatments that reduce frequency of COPD-related exacerbations are associated with lower COPD-related medical costs. 40% of COPD costs could be avoided by preventing complications and hospitalizations.Individuals with COPD had more days of lost productivity than any other chronic condition.

16. COPD – Global Initiative for Chronic Obstructive Lung DiseaseStage IMild COPDFEV1/FVC<0.70FEV1≥ 80% normalStage IIModerate COPDFEV1/FVC<0.70FEV1 50-79% normalStage IIISevere COPDFEV1/FVC<0.70FEV1 30-49% normalStage IVVery Severe COPDFEV1/FVC<0.70FEV1 <30% normal, or <50% normal with chronic respiratory failure present** Usually, this means requiring long-term oxygen therapy.GOLD COPD staging uses four categories of severity for COPD, based on the value of FEV1

17. COPD – Global Initiative for Chronic Obstructive Lung DiseaseStable COPD

18. COPD – Global Initiative for Chronic Obstructive Lung DiseaseExacerbations of COPD are defined as acute changes in symptoms (cough, dyspnea and sputum production) beyond what is considered normal variability in a patient and leads to a change in medications

19. COPD – Global Initiative for Chronic Obstructive Lung DiseaseTreatment optionsOxygen- titrated to SpO2 88%-92%Bronchodilators – short actingSystemic corticosteroids – shorten recovery time, improve lung function and PaO2, reduce risks of early relapse and treatment failure and LOS40 mg prednisone daily (or equivalent) x 5 days is recommendedAntibioticsWith all 3 cardinal symptoms of: Dyspnea, sputum volume and sputum purulenceIncreased sputum purulence + one other cardinal symptomMechanical ventilationAnti-pseudomonal agents should be used for pt’s at risk for colonization or new infection

20. COPDRisk factors for pseudomonal infection include:recent hospitalization (≥2 days' duration during the past 90 days)frequent administration of antibiotics (≥4 courses within the past year),severe COPD (FEV1 <35 percent of predicted or < 1L)isolation of Pseudomonas aeruginosa during a previous exacerbationcolonization during a stable periodsystemic glucocorticoid use

21. COPDNoninvasive positive pressure ventilation (NIPPV) improves numerous clinical outcomes and is the preferred method of ventilatory support in many patients with an acute exacerbation of COPD. Avoidance of hypoxemia is critical, even if oxygen therapy worsens hypercarbiaInvasive mechanical ventilation is required in patients with respiratory failure who fail NIPPV, do not tolerate NIPPV, or who have contraindications to NIPPV.Careful attention to ventilation parameters is needed in patients with severe obstruction

22. COPDSeveral measures have been shown to reduce chronic obstructive pulmonary disease (COPD) exacerbationssmoking cessation pulmonary rehabilitationproper use of medications (including metered dose inhaler technique)vaccination against seasonal influenza and pneumococcusMedications, such as tiotroprium and combination inhaled glucocorticoid and long-acting beta agonists(LABA) can help to reduce the frequency of COPD exacerbationsroflumilast and N-acetylcysteine (NAC) may also be of benefit

23. COPDPROGNOSIS — Exacerbations of COPD are associated with increased mortality with in-hospital mortality ranges from three to nine percent Mortality following hospital discharge after an exacerbation of COPD is influenced by a number of factors, including age, the severity of the underlying COPD, presence of hypercapnia, and the presence of Pseudomonas aeruginosa in the patient’s sputum as described in the following studies:It is estimated that 14 percent of patients admitted for an exacerbation of COPD will die within three months of admissionIn those with an exacerbation of COPD and a PaCO2 of 50 mmHg or more, the 6 and 12 month mortality rates have been reported at 33 and 43 percent, respectively.In a study of 260 patients admitted with a COPD exacerbation, the one year mortality was 28 percent. Independent risk factors for mortality were age, male gender, prior hospitalization for COPD, PaCO2 ≥45 mmHg (6 kPa), and urea >8 mmol/L.Patients hospitalized for a COPD exacerbation who have Pseudomonas aeruginosa in their sputum have a higher risk of mortality at three years than those without (59 versus 35 percent, HR 2.33, 95% CI 1.29-3.86), independent of age, comorbidity, or COPD severity Even if the COPD exacerbation resolves, many patients never return to their baseline level of health

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