Asthma and COPD: Disclosures

Clinical Pearls for Management

• Grants: Novartis, Daiichi-
Wendy L. Wright, MS, APRN, BC, FAANP
Adult / Family Nurse Practitioner
Sankyo
Owner - Wright & Associates Family Healthcare • Speaker Bureau: Ortho-McNeill
Ortho-McNeill,
Amherst, New Hampshire Abbott, Novartis, GSK, Sanofi-
Co-owner- Anderson Family Healthcare
Pasteur, Daiichi-Sankyo, Merck
Concord, NH
Partner – Partners in Healthcare Education, PLLC

Wright, 2011 1 Wright, 2011 2

Objectives

Upon completion, the participant will be able

to:
1. Identify statistics related to
/p
incidence/prevalence of asthma and COPD
2. Discuss the signs and symptoms of
Asthma
asthma and COPD
3. Discuss treatment options for asthma
and COPD

Wright, 2011 3 Wright, 2011 4

Asthma is... Prevalence of Asthma

• Impacts approximately 21 million individuals
• Derived from the Greek word for panting in the United States
or breathlessness • Most common chronic disease of childhood
• Recurrent airflow obstruction caused by affecting 6 million children
chronic airway inflammation with a • Before adolescence, 2 times more common
superimposed bronchospasm in boys
• Leads to… wheezing, breathlessness and • Increasing incidence of this disease
a cough – 76% increase in the prevalence of asthma
within the past decade
Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. NIH, NHLBI. June 2002. Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. NIH, NHLBI. June 2002.
NIH publication no. 02-5075. NIH publication no. 02-5075.
Wright, 2011 5 Wright, 2011 6

Wright, 2011 1
 Impact of Asthma Why Is the Death Rate Increasing?

• Most frequent cause for hospitalization in

children (470,000 each year)
• Multifactorial
– Emergency room visits and hospitalizations –Asthma is increasing
are increasing –Asthma
Asthma is more severe
• Most frequent cause of childhood death, –Poor management of the disease
particularly amongst certain groups
(children, african americans)
–Poor patient compliance
– 4000 - 5,000 people die yearly from –Inadequate patient and provider
asthma
Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma-United States, 1980-1999.
response to signs of worsening trouble
MMWR Surveill Summ. 2002;51:1-13.
Wright, 2011 7 Wright, 2011 8

Misconceptions and Facts Misconceptions

• Asthma symptoms can begin at any age • Most people think that children will
• Most often misdiagnosed or outgrow asthma…
underdiagnosed in the elderly – Children who suffer from intermittent
wheezes have a 50% chance or better of
– Fail to report symptoms because it is outgrowing this disease
thought to be normal – Children with persistent wheezing have
– Attribute the symptoms to comorbid only a 5% chance of outgrowing this
diseases disease
Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma-United States, 1980-1999.
MMWR Surveill Summ. 2002;51:1-13. Fuerra S, Wright AL, Morgan WJ, et al. Persistence of asthma symptoms: role of obesity
and onset of puberty. Am J Respir Crit Care Med. 2004;170:78-85.
Wright, 2011 9 Wright, 2011 10

Pathophysiology of Asthma Pathophysiology of Asthma

• Genetic predisposition • IgE/allergen complex - then attaches itself

– Chromosome: 5Q31-Q33 to the mast cells on the nasal and
• Results from repeated exposure to bronchial mucosa
allergens in the individual already
equipped with the genetic predisposition • Release of numerous chemical mediators
• Upon exposure to an allergen, there is a
release of IgE antibodies
• IgE antibody binds with the antigen

Wright, 2011 11 Wright, 2011 12

Wright, 2011 2
 Components of Asthma
Histamine
Asthma Triggers

Allergens Exercise Irritants Viruses Weather

• Histamine is stored mainly in the mast cell
Smooth Muscle
– Circulated in the blood via the basophil Dysfunction
Inflammation

• Causes an increase in blood flow to the Mucus

affected area. Hypertrophy
Hyperplasia
A hit t
Secretion
Architectural
l
Edema
I
Impaired
i d
Epithelial
– Responsible for the increased nasal
Inflammatory Changes Ciliary
Mediator Damage
Function

discharge, edematous mucous membranes,

Release

Bronchial Constriction Bronchial Hyperreactivity Inflammatory Cell Infiltration

sneezing, itchy nose and eyes, and hives
– Also associated with airway inflammation and
bronchoconstriction Symptoms

Exacerbations
Wright, 2011 13 Wright, 2011 14
Adapted from Creticos. Adv Stud Med. 2002;2(14):499-503.

Consequences of Inflammation in Asthma Asthma: Pathophysiologic Features

Stimulus and Changes in Airway Morphology
(Antigen, virus, pollutant, occupational agent) Airway lumen narrowing

Epithelial
Mucous gland damage
Altered airway physiology hypertrophy
Acute and hyperplasia
 Airflow obstruction Inflammation
Airway smooth-
muscle hypertrophy,
hyperplasia, and
Edema b
bronchoconstriction
h t i ti
Resolution
Inflammatory
 Airway dysfunction Chronic Inflammation cell infiltration
Mucus
hypersecretion
Injury Repair
Vascular
Thickening dilation
of basement
“Permanently” altered Remodeling membrane Goblet cell
lung function (fixed changes in the hyperplasia
structure of airway)
Adapted from Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma.
Wright, 2011 15
NIH, NHLBI. 1991. NIH publication 91-3042. Wright, 2011 16

Cross Section of Bronchiole Showing

Bronchospasm
Epithelial Damage in Asthma

Color Atlas of Respiratory Disease. Volume 2, 1995. Normal Asthmatic

Wright, 2011 17 Jeffery P. In: Asthma, Academic Press 1998.
Wright, 2011 18

Wright, 2011 3
 Basement Membrane Thickening
Triggers

• Inhalant allergens are the most common

triggers for both asthma
– House dust
– Pollens
– Mold spores
– Animal and insect emanations
• Cockroach feces

Jeffery P. In: Asthma, Academic Press 1998.

Wright, 2011 19 Wright, 2011 20

Triggers Triggers

• Chemicals
• Tobacco smoke
• Perfumes
• Foods • Pollution
– Sulfites (wine), shrimp, dried fruit, –Work exposures
processed potatoes, beer • Exercise
• Viruses or infections
• Cold air
Wright, 2011 21 Wright, 2011 22

Gastroesophageal Reflux - A Asthma is...

Significant Factor in Children
• 84 healthy infants and children referred for an
evaluation of daily wheezing • A disease of:
– All evaluated for reflux –Inflammation
– 64% had positive evaluations for reflux • Primary Process
– After 3 months on anti-reflux treatment, –Hyperresponsiveness
64.8% of the infants/children were able to
–Airway bronchoconstriction
discontinue all daily asthma medications
(including nebulized flunisolide) –Excessive mucous production
Sheikh S. et. Al. Pediatric Pulmonology. 1999 Sep; 28(3):
181-6 Wright, 2011 23 Wright, 2011 24

Wright, 2011 4
 Diagnosis of Asthma

• History and Physical Examination

Diagnosis of Asthma • Spirometry
p y is needed to make
diagnosis
• Monitoring:
–Peak Flow Meters

Wright, 2011 25 Wright, 2011 26

Symptoms and Signs of Asthma Methods for Measuring Airway

in Children and Adults Caliber

• Coughing, particularly at night or

after exercise
• Wheezing
• Chest tightness
• SOB
• Cold that lingers x months Maximum PEFR FVC, FEV1 Airway
airflow achieved FEF25%-75% Resistance

Home Office/Clinic Clinic/Laboratory

Wright, 2011 27 Wright, 2011 28

Asthma Findings

• Typically, reversibility of 12% or

greater after administration of a
bronchodilator aerosol is
consistent with asthma.

Conboy-Ellis, Kathleen. Asthma: Pathogenesis and Management. The Nurse

Practitioner: November 2006; Vol.31, No. 11. 24 – 39.
Wright, 2011 29 Wright, 2011 30
 2008 Fitzgerald Health Education Associates, Inc. 29

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 Changes With Age in FEV1 According
Rate of Decline in FEV1 to Smoking and Asthma Status
1.0 Male Smokers Male Nonsmokers
1.7 1.7
No asthma (n=9332) No asthma (n=5480)
1.5 Asthma (n=630) 1.5 Asthma (n=314)
0.8
1.3 1.3
Height- Height-
06
0.6 Adjusted 1.1 11 Adjusted
Adj t d 1.1
11
FEV1/Ht3 FEV1 (liters) FEV1 (liters)
(L/m3) 0.9 0.9
0.4
0.7 0.7
Normal subjects (n=186)

0.2 Asthma patients (n=66) 0.5 0.5

0.3 0.3
0 20 30 40 50 60 70 80 20 30 40 50 60 70 80

0 20 40 60 80 Age (yr) Age (yr)

Age (Yrs.)
Wright, 2011
Adapted from Peat. Eur J Respir Dis. 1987;70:171. 31 Lange et al. N Engl J Med. 1998;339:1194-1200.
Wright, 2011 32

The Biggest Predictor of

Asthma
Sudden Death from Asthma

• Hyperinflation
• History of hospitalization with or • Diaphragm is
without intubation down to the 11th
• These individuals are at a significant ribs
risk for a serious exacerbation again • Most patients with
asthma have
normal x-rays
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Chronic Asthma Changes

• Increased AP Lateral
diameter
• The way you know that
AP/Lat diameter is increased
is by this clear space
Treatment of Asthma
between the sternum and
the ascending aorta
• Flat diaphragms

35 Wright, 2011 36

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 Evolution of Asthma Paradigms Environmental Control:
A Useful but Often Ignored Step

• Dust Mite Avoidance

– Bed linens must be laundered 1-2 times/week
– Maintain humidity at <50%
– Encase
E pillows
ill and
d mattresses
tt
– Frequent vacuuming
Bronchial Fixed
Symptoms Hyperreactivity Obstruction • Remember: 30 minutes after vacuuming:
increased dust mite emanations in the air
• Individuals with significant asthma should avoid
Prevent Symptoms
Prevent Symptoms vacuuming or avoid the room for 30 minutes
Relieve Symptoms Prevent Attacks
Prevent Attacks
Prevent Remodeling after vacuuming
Wright, 2011 37 Wright, 2011 38

Environmental Control: A Useful Environmental Control

but Often Ignored Step
• Animal Avoidance
• Pollen Avoidance – Keep animals out of the bedroom
– Air-conditioning – If the family has a cat, weekly washing of the
– Minimize outdoor exposures during times of cat significantly reduces the allergen load
highest pollen counts – May have to remove animals from home
– Keep bedroom windows closed – Dry clean upholstery and carpets
– Air filters – Cover with an air filter any ducts leading into
the bedroom

Wright, 2011 39 Wright, 2011 40

Environmental Control Environmental Control

• Mold Avoidance • Avoidance of Non-allergic Triggers

– Children/adolescents with allergic rhinitis –Strong emotions
and/or asthma should not be sleeping in a
damp basement
–Smoke: No smoking in house or car
– Clean moldy surfaces –Pollution
– Avoid houseplants –Cold air
– Avoid chores that involve damp grass, leaves –Odors
–Exercise
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 Childhood Asthma Control Can How Are We Doing With Treatment?
Predict Adult Lung Status
• Study looking at treatment of children over 10
• Study of 119 asthmatic children during year period showed an increase in the number
1966 and 1969 of prescriptions for beta agonists
– 4.0% up to 8.1%
• Ages:
g 5-14 were evaluated using
g FEV1 • However
However, despite the significant increase in
• Follow-up performed 17-18 years later beta agonist prescriptions, there was only a
and 27-28 years later slight increase in anti-inflammatory medications
prescribed (even amongst children using 2+
• Children who were well controlled during rescue inhalers/month)
childhood had the smallest decline in – 0.4% up to 2.4%
total lung volume during adulthood Goodman, DC et. Al. Pediatrics 1999 Aug; 104(2) 187-94
Wright, 2011 43 Wright, 2011 44

Stepwise Approach for Managing Asthma

in Patients Aged 12 Years: Step Approach to Therapy
NAEPP EPR-3 Guidelines

Severe Persistent • If control is not achieved with

therapy, step up the therapy
Moderate Step 6
Mild Persistent Step 5 Preferred:
Intermittent Persistent Step 4 High-dose ICS +
Preferred:
Step 3
• Once control is sustained for a
Preferred: High-dose ICS + LABA + oral
Step
p2 corticosteroid
S
Step 1 Preferred: Medium dose
Medium-dose LABA
Preferred: Medium-dose ICS + LABA and

minimum of 3 months, can consider

Preferred: and
Low-dose inhaled ICS
SABA prn Alternative: omalizumab use consider
corticosteroid (ICS)
or Medium-dose can be omalizumab for

stepping down the therapy

Alternative: ICS considered for patients who
Low-dose ICS +
and either patients who have allergies
Mast cell stabilizer LABA
LTRA, have allergies.
(Cromolyn
Alternative: theophylline,

• Regardless, therapy should be

nedocromil),
Low-dose ICS or zileuton
leukotriene
and either
receptor antagonist

reviewed q 6 months
LTRA,
(LTRA),
theophylline,
or
or zileuton
theophylline
Wright, 2011 45 Wright, 2011 46
45

Major Focus in EPR-3

• Controlling asthma is a
major focus of the EPR-3
guidelines
id li

Wright,
47 2011 Wright,
National Heart, Lung and Blood Institute; National Asthma Education and 2011 48
Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis
and Management of Asthma, Full Report 2007.

Wright, 2011 8
 Monitoring Control in Clinical Practice:
Asthma Control Test™ for Patients Aged ≥12 Years1 Short Acting Inhaled Beta 2 Agonists
Level of
Control Based
on Composite
Score2 • Albuterol (Proventil HFA, Ventolin HFA)
≥20 =
Controlled – 90mcg/puff, 200 puffs
16 19 =
16-19 – 2 puffs q 4
4-6
6 hours or 2 puffs 15 minutes before
Not Well
Controlled exercise
≤15 = – Onset: 5 minutes
Very Poorly
Controlled
Regardless of
patient’s self
assessment of
control in
Question 5
1. Asthma Control Test™ copyright, QualityMetric Incorporated 2002, 2004. All rights reserved.
2. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/epr3/resource.pdf. Accessed February 5, 2007.
Wright, 2011 49 Wright, 2011 50

Short Acting Beta-2 Agonist Short-Acting Beta-2 Agonists

• Levalbuterol (Xopenex HFA)

–1 – 2 inhalations every 4 – 6 • Usage of these medications more
hours prn than 2 times/week is indicative of
poor control
• Regular, scheduled use of these
medications is usually not
recommended
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Maintenance or Prevention is the Key

• Good management is the key to

preventing exacerbations and
Long-Acting Controller
C ll hospitalizations
Medications • As with any disease, preventing the
problem is always better than treating
it
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 Corticosteroids
Inhaled Corticosteroids

• Examples
• Most potent and effective anti- – Beclomethasone (Beclovent, Vanceril)
inflammatory medication currently – Budesonide ((Pulmicort turbuhaler))
available – Flunisolide (Aerobid)**
– Fluticasone (Flovent)
– Triamcinolone Acetonide (Azmacort)**
– Mometasone (Asmanex)

**No longer sold in the U.S.

Wright, 2011 55 Wright, 2011 56

Inhaled Corticosteroids To Reduce Side Effects of Inhaled

Corticosteroids
• Side effects
– Pharyngitis • Administer with spacers or holding
– Dysphonia chambers
– Oral
O l Candidiasis
C didi i
• Rinse mouth after inhalation
• Precautions
– High dosages: Increased systemic
• Use lowest possible dose to maintain
absorption leading to HPA axis suppression control
– Not indicated for an acute exacerbation • Children - monitor growth
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Schenkel, E. et. al Remember...

• 98 patients randomized to either placebo or

mometasone furoate aqueous nasal spray • Poorly controlled asthma often
• Ages: 3 - 9 years delays growth
• After 1 year, there was no suppression of • In general, children with asthma
height in the children using the nasal
corticosteroid when compared with the child tend to have longer periods of
using placebo reduced growth rates prior to
puberty
Pediatrics Vol 105 No. 2 February 2000, p. 22
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 Non-steroidal Inhaled Antiinflammatory
Mast Cell Stabilizers Medication

• Cromolyn Sodium (Intal) • Nedocromil Sodium (Tilade)

– Best for mild - moderate disease
• Indications
– Works by reducing the production of
–Asthma
Asthma prophylaxis histamine and by preventing the release from
–Prevention of bronchoconstriction before the mast cells
exposure to suspected allergen – MDI: >6 years: 2 sprays qid
• Best for mild-moderate disease – Nebulizer: >2 years
• May be the initial choice for children • 0.5% solution; 1 ampule qid
Wright, 2011 61 Wright, 2011 62

Mast Cell Stabilizers Leukotriene Receptor Antagonists

• Soon to be / already are… • Cysteinyl leukotriene production in the

body has been associated with airway
–No longer available in United edema, smooth muscle constriction and
States the inflammatory process
• These medications block the leukotriene
receptors which in turn is able to
prevent inflammation and
bronchoconstriction

Wright, 2011 63 Wright, 2011 64

Leukotriene Receptor
Zafirlukast (Accolate)
Antagonists
• Drug/Drug Interactions
• (Zafirlukast) Accolate – Aspirin: Increased zafirlukast levels by
– 10mg bid for ages 5-11 40%
– 20mg bid for 12 and older – Erythromycin: 40% decrease in
– Studied in children as young as 5 zafirlukast
– Avoid food 1 hour before and 2 hours after taking:
Food decreases the bioavailability of Accolate – Theophylline: Postmarketing reports of
– Metabolism: Metabolized through the CY P450 2C9 increased theophylline levels
and 3A4 pathways – Coumadin: 35% increase in PT/INR
• Major pathways in the body
• Numerous other medications use this same pathway
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Wright, 2011 11
 Zafirlukast (Accolate) Montelukast (Singulair)
• Side effects
– Headache (12.9%) • (Montelukast) Singulair
– Dizziness – 4 mg Granules once daily: 12 – 23 months
– Nausea
N –4
4 mg tablet
t bl t ffor children
hild 2 - 5 years off
– Churg Strauss syndrome age
• Pregnancy: B –5mg qhs for ages 6-14
• Precautions –10mg qhs for ages 15 and older
– Not for an acute exacerbation
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Montelukast (Singulair)
Methylxanthines

• Drug Interactions • Theophylline

– Metabolized through CYP2A6 (minor pathway)
– Phenobarbital: decreases montelukast but no
dosage adjustment is required
• Side effects: headache, fatigue, dizziness,
Churg-Strauss
• Precautions
– Not for an acute exacerbation
• Category: B Wright, 2011
– Theo-24, Theo-Dur, Uni-Dur, Slo-Bid
– Bronchodilates and increases the force with which
the diaphragm contracts
– 6 years and older
– Difficult to manage and as a result has not really
gained wide spread acceptance
– Indicated for individuals with moderate to severe
asthma
69 – Numerous drug interactions
Wright, 2011 70

Theophylline Theophylline

• Numerous medications, foods and chemicals

interact with theophylline • Theophylline levels (normal 6-15mcg/dL)
– All of the following decrease theophylline levels – 15-25: GI upset, N/V, diarrhea, abdominal
• Smoking (cigarettes and marijuana) pain
i
• High protein/low carbohydrate diet
• Phenytoin
– 25-35: Tachycardia, occasional PVC’s
• Phenobarbital – >35: Ventricular tachycardia, seizures
• Carbamazepine
• Category: C
• Ketoconazole
• Diuretics
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 Long Acting Inhaled Beta 2 Agonist Long Acting Inhaled Beta 2 Agonist

• Salmeterol (Serevent)
– Diskus • Foradil Aerolizer
• >4 years of age-1 puff po q 12 hours – > 5 years of age: 1 inhalation every 12
hours
– No role for acute exacerbations
– Also may be used for prevention of EIB
– Seems to help children affected by the
nocturnal cough and wheezing
– Good for prevention of exercise induced
asthma

Wright, 2011 73 Wright, 2011 74

LABA Omalizumab (Xolair)

• FDA warning regarding increased • Indicated for adults and adolescents (12
deaths in patients treated with years of age and above) with moderate to
severe persistent asthma who have a
LABA positive skin test or in vitro reactivity to a
–Should
Sh ld beb used d only
l with
ith inhaled
i h l d perennial
i l aeroallergen
ll
corticosteroid • And…whose symptoms are inadequately
controlled with inhaled corticosteroids
–Should be used for shortest length
• SC injection
of time to control symptoms
www.fda.gov/CDER/Drug/infopage/LABA/default.htm accessed
07-20-2010
Wright, 2011 75 Wright, 2011 76

Omalizumab (Xolair) Last….

• Recombinant DNA-derived humanized IgG1 • Don’t forget to treat the nose

monoclonal antibody that selectively binds to
human immunoglobulin E (IgE). • 85% of individuals with asthma
• Inhibits the binding of IgE to the high-affinity
high affinity have concomitant allergic
IgE receptor on the surface of mast cells and rhinitis
basophils
• Limits the degree of release of mediators of
the allergic response.

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 Acute Asthma Exacerbation

• Measure FEV1
• Inhaled short acting beta 2 agonist: Up to
Acute Asthma Exacerbation three treatments of 2-4 puffs by MDI at 20
minute intervals OR a single nebulizer
Management • Can repeat x 1 – 2 provided patient tolerates
• Prednisone
– What dose and schedule??

Wright, 2011 79 Wright, 2011 80

Management of Moderate Exacerbations: Management of Moderate Exacerbations:

Response from ED Treatment Response from ED Treatment

• Good Response • Incomplete Response

–Symptom relief sustained x 1hr; FEV1 or – Mild-moderate symptoms, FEV1 or PEF
40-69%
PEF ≥ 70% – SABA,
SABA oxygen, orall or IV corticosteroids
ti t id
–D/C home – Can D/C home
–Continue SABA & oral corticosteroid • Poor Response
– Marked symptoms, PEF <40%
–Consider inhaled corticosteroid (ICS) – Repeat SABA immediately
–Patient education / asthma action plan – ED / 911; oral corticosteroid
Wright, 2011 81 81 Wright, 2011 82 82

Key Differences in the EPR-3 Report

• Point of discharge
–FEV1 or PEF ≥ 70% predicted
–Response sustained 60 minutes after COPD
last treatment
–Normal physical exam
• Continued ED treatment needed
–FEV1 or PEF 40-69% predicted
• Consider adjunct therapies
–FEV1 or PEF <40% predicted
Wright, 2011 83 83 Wright, 2011 84

Wright, 2011 14
 Case Study Case Study

• 55 year old male • PMH

• Presents with 3 year history of –Asthma in childhood
worseningg sob on exertion
• ROS
• Present x 10 years
–Wheezing with exercise and URI’s
• Denies chest pain, diaphoresis,
–Sputum production every
lightheadedness
morning
• Smoker x 35 years; 1 ppd
Wright, 2011 85 Wright, 2011 86

Case Study COPD

• Physical examination • Disease characterized by airflow

–VSS limitation that is not fully reversible
–HEENT:
HEENT: normal • Airflow limitation is usuallyy both
progressive and associated with an
–Heart: S1, S2, RRR; no S3, S4
abnormal inflammatory response of
–Lungs: clear but diminished the lungs to noxious particles or
–O2 sat – 97% on RA gases
Statement from Global Initiative for Chronic Lung Disease (GOLD)
Wright, 2011 87 Wright, 2011 88

Per goldcopd.org Per goldcopd.org

• Chronic bronchitis is a clinical • Emphysema is an anatomic

diagnosis characterized by a diagnosis. It is the abnormal,
cough productive of sputum for permanent enlargement of
over 3 months’ duration during airspace distal to the terminal
2 consecutive years and the bronchioles, accompanied by
presence of airflow obstruction. destruction of the walls and
without obvious fibrosis.
Utilized with permission from Fitzgerald Health Education Associates, 2007 Utilized with permission from Fitzgerald Health Education Associates, 2007

Wright, 2011 89 Wright, 2011 90

Wright, 2011 15
 Risk Factors for Development Risk Factors for Development
• Smoking • Age
–75% of COPD worldwide is –Beginning at age 35 – average
attributable to smoking yearly loss of FEV1 is 25 –
–90%
90% of COPD in the US is 30mL/year
attributable to smoking • Indoor/outdoor pollution
• Approximately, 15-20% of smokers • Genetic factors
will develop COPD
MacNee, W, ZuWallack, R.L, Keenan, J. Clinical Management –Alpha1 antitrypsin
Of Chronic Obstructive Pulmonary Disease; 2005. 1st edition. MacNee, W, ZuWallack, R.L, Keenan, J. Clinical Management
Professional Communications, Inc; West Islip, NY. Of Chronic Obstructive Pulmonary Disease; 2005. 1st edition.
Professional Communications, Inc; West Islip, NY.
Wright, 2011 91 Wright, 2011 92

Incidence/Prevalence Comorbidities
• Significant number of associated
• 12 million Americans with comorbidities
diagnosis
–Osteoporosis
• 10-12 million Americans who –Hypertension
remain undiagnosed
–Weight loss
• 4th leading cause of death in US –Depression
–Cancer
Wright, 2011 93
–CAD Wright, 2011 94

Spirometry in the Spirometry in the

diagnosis of COPD diagnosis of COPD

• Two most important measures • Spirometric evidence of obstruction if

• Forced expiratory volume in first FEV1/FVC ratio < 70%
second of expiration (FEV1) • The degree of spirometric abnormality
generally reflects the severity of COPD
COPD.
• Forced vital capacity (FVC) (total
respiratory effort) • A patient with an FEV1/FVC of 70% and
a normal FEV1 has stage I COPD
• FEV1 to FVC ratio= Considered the most • Subjective symptoms are occasionally
sensitive indicator of early airflow absent and are not required for
limitation diagnosis.
Utilized with permission from Fitzgerald Health Education Associates, 2008 Utilized with permission from Fitzgerald Health Education Associates, 2008
Wright, 2011 95 Wright, 2011 96

Wright, 2011 16
 Spirogram Spirometry Testing

• CPT codes
10

–94010: $32.84 (FEV1/FVC)

8
L/sec)

–94060:
94060: $56.65
$56 65 (spirometry before
6
Normal
Flow (L

5 Moderate Obstructive

and after bronchodilator)

Severe Obstructive
4

–94375: $36.81 (flow loop)

2

–94620: $64.59 (pulmonary stress

0
0 1 2 3 4 5 6

Volume (L)
test)
Wright, 2011 97 Wright, 2011 98

Utilized with permission from Fitzgerald Health Education Associates, 2007

Who to Test for Alpha1
Antitrypsin Deficiency

• COPD
• Family history
• Early onset of Emphysema
– Usually found in individuals under 30
years of age
• Unexplained liver disease
Increased A-P Diameter
• Emphysema without risk factors
Low, Flattened Diaphragm
Air Trapping
Wright, 2011 99 Wright, 2011 100

Case Study Case Study

• Spirometry Test Results
– FEV1
• Spirometry Test Results
• Pre-bronchodilator: 2.22 L (69%) –FEV1/FVC
• Postbronchodilator: 243 L ((76%)) • Pre: 53%
• Change: 9%
• Post: 55%
– FVC
• Pre: 4.22 L (107%)
• Post: 4.45 L (113%)
• Change: 5%

Wright, 2011 101 Wright, 2011 102

Wright, 2011 17
 Therapy at Each Stage of COPD
I: Mild II: Moderate III: Severe IV: Very Severe What Stage is Our Patient?
• FEV1/FVC < 70%
 FEV1 < 30%
predicted

•FEV1/FVC < 70% FEV1/FVC < 70%

 FEV1/FVC < 70%

 30% < FEV1 <

or FEV1 < 50%
predicted plus
• Stage I
chronic
 FEV1 > 80%
predicted
 50% < FEV1 <
80% predicted
50% predicted
respiratory failure
• Stage II
Active reduction of risk factor(s); influenza vaccination • Stage III
Add short-acting bronchodilator such as albuterol (salbutamol) (when needed)
Add regular treatment with one or more long-acting
bronchodilators such as tiotropium (Spiriva) or ipratropium
• Stage IV
bromide (Atrovent), salmeterol (Serevent), formoterol (Foradil) or
arformoterol (Brovana) (when needed); Add rehabilitation
Add inhaled corticosteroids if repeated
exacerbations, for example, =>3
exacerbations in 3 years
Add long term oxygen if
chronic respiratory failure.
Wright, 2011 Consider surgical treatments
103 Wright, 2011 104

What Would You Initiate? Bronchodilators

• What would you do? • Mainstay of pharmacological

• Which medication would you treatment
choose?? –Short
Short (albuterol) and long acting
(formoterol, salmeterol,
aformoterol)
–Improve emptying of lungs,
exercise tolerance and reduce
hyperinflation
Wright, 2011 105 Wright, 2011 106

Anticholinergics Long-term oxygen therapy

• Ipratropium bromide
– Atrovent HFA • Goal
• 2 inhalations 4x per day
• Contraindication: peanut allergy – To ensure adequate oxygen delivery
• Tiotropium bromide (Spiriva) to the vital organs by increasing the
– 1 inhalation once daily baseline PaO2 at rest to => 60 mm
– Indicated to reduce exacerbations Hg at sea level and/ or producing a
• Ipratropium bromide/albuterol
(Combivent) SaO2=> 90%.
– 2 puffs 4x per day
Utilized with permission from Fitzgerald Health Education Associates, 2008
Wright, 2011 107 Wright, 2011 108

Wright, 2011 18
 Long-term oxygen therapy Pulmonary Rehab
• Indications to initiate long-term • Exercise training
(> 15 hours/day) oxygen therapy • Nutrition counseling
– PaO2< 55 mm Hg or SaO2< 88% with
or without hypercapnia • Education
– PaO2 55-59 mm Hg or SaO2= 89% in • Conducted over 6 weeks
the presence of cor pulmonale, right
heart failure, or polycythemia (hct> • Improves exercise performance
56%) and reduces dyspnea (no
• Source- www.goldcopd.org improvement on FEV1)
Utilized with permission from Fitzgerald Health Education Associates, 2008

Wright, 2011 109 Wright, 2011 110

Surgery

• Bullectomy
• Lung Volume Reduction Surgery Thank You For Your
• Lung transplant surgery Time and Attention!!!

Wright, 2011 112

Wright, 2011 111

Wright, 2011 19