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Heba Ismail, MD
Assistant clinical Professor
Division of Pulmonary and Critical Care Medicine
University of California, Irvine Medical Center
E-mail, ismailh@uci.edu
Disclosure
None
Definition
The international Global initiative on Chronic
Obstructive Lung Disease (GOLD), (WHO/NIH
2009) defines COPD as:
Mucus Hypersecretion
Pulmonary Hypertension
Systemic Features
COPD
No blood test, imaging study, or lung function can
completely describe impairment from COPD.
COPD is the 4th leading cause of mortality in the USA, and is also
the only one of the top five leading causes of death that is
continuing to rise, doubling from 1970 to 2002
COPD deaths among women in the USA have been rapidly rising
since the 1970s and have exceeded male COPD deaths since 2000
Epidemiology
COPD presents an increasing social and economic burden.
BUT
Unable to halt the annual decline in FEV1 or
unequivocally reduce mortality, with the
important exception of oxygen therapy where
indicated.
Oxygen Therapy
Long-term oxygen therapy (more than 15 hours
a day) has been shown to
Improve survival
Exercise tolerance
Pulmonary hemodynamics including pulmonary artery pressure,
lung mechanics and mental status.
Indications of long term oxygen therapy include:
PaO2 at or below 55 mmHg or/ SaO2 of less than or equal to
88%
PaO2 between 55 mmHg and 60 mmHg, SaO2 of 89% if there is
evidence of pulmonary hypertension, peripheral edema
suggesting congestive heart failure or polycythemia.
Pharmacotherapy
Bronchodilators
They do not alter the decline in lung function.
They decrease expiratory trapped air volume
and reduce dynamic hyperinflation during
exercise as well as at rest.
They are prescribed in both short- and long-
acting forms for immediate (rescue) and
sustained relief, respectively.
Pharmacotherapy
Long-acting bronchodilators are recommended for
patients with moderate to severe COPD.
Salmeterol and Fluticasone Propionate and Survival in Chronic Obstructive Pulmonary Disease
Peter M.A. Calverley, M.D., Julie A. Anderson, M.A., Bartolome Celli, M.D., Gary T. Ferguson, M.D., Christine Jenkins, M.D., Paul W. Jones, M.D., Julie C. Yates, B.S., and Jrgen
Vestbo, M.D. for the TORCH investigators
N Engl J Med 2007; 356:775-789February 22, 2007DOI: 10.1056/NEJMoa06307
Pharmacotherapy
Tiotropium, was assessed in a randomized trial Understanding Potential
Long-Term Impacts on Function with Tiotropium (UPLIFT).
Among patients with moderate (45%) and severe (44%) COPD, Tiotropium
or placebo was added to ongoing care, that is, inhaled corticosteroids,
long-acting beta-2 agonists, and/or theophylline, for a duration of 4 years.
The most common side effects were also diarrhea and nausea.
PDE-4 Inhibitors
Two randomized clinical trials on the use of Roflumilast
compared to placebo were published in 2009.
Patient selection
most investigators have attempted to identify optimal surgical
candidates on the basis of pulmonary function and radiographic
features
Bullectomy
Patient Selection
Lung Volume Reduction Surgery
LVRS
LVRS, NETT
Methods
A total of 1218 patients
with severe emphysema
underwent pulmonary
rehabilitation and were
randomly assigned to
undergo lung-volume
reduction surgery or to
receive continued medical
treatment
LVRS, NETT
LVRS, NETT
Results
Overall mortality was 0.11 death per person-year in both treatment
groups.
With the exclusion of a subgroup of 140 patients at high risk for death
from surgery according to an interim analysis, overall mortality in the
surgery group was 0.09 death per person-year, as compared with 0.10
death per person-year in the medical-therapy group (risk ratio, 0.89;
P=0.31).
Methods
Searches for appropriate studies were undertaken on
PubMed and Clinical Trials Databases using the search
terms COPD, emphysema, lung volume reduction and
endobronchial valves
Thorax. 2014 Mar;69(3):280-6. doi: 10.1136/thoraxjnl-2013-203743. Epub 2013 Sep 5. Current status of
bronchoscopic lung volume reduction with endobronchial valves. Shah PL1, Herth FJ.
Current status of bronchoscopic lung
volume reduction with endo-bronchial
valve
Results
The evidence from the randomized clinical trials suggests that complete
lobar occlusion in the absence of collateral ventilation or where there is
an intact lobar fissure are the key predictors for clinical success.
Thorax. 2014 Mar;69(3):280-6. doi: 10.1136/thoraxjnl-2013-203743. Epub 2013 Sep 5. Current status of bronchoscopic
lung volume reduction with endobronchial valves. Shah PL1, Herth FJ.
Current status of bronchoscopic lung
volume reduction with endo-bronchial
valve
Conclusion
Thorax. 2014 Mar;69(3):280-6. doi: 10.1136/thoraxjnl-2013-203743. Epub 2013 Sep 5. Current status of bronchoscopic lung volume reduction with
endobronchial valves. Shah PL1, Herth FJ.
This article describes first experiences in a patient with five
endobronchial valves in the right upper lobe who needed urgent
surgery due to lumbar disc herniation with neurological
impairment.
Head/neck procedures
Procedures involving the airway carry an increased risk of postoperative pneumonia
Management of secretions in the patient who has undergone laryngectomy may require
early postoperative humidification.
Orthopaedic procedures
Orthopedic procedures are associated with a relatively high frequency of venous
thromboembolism
In the patient with COPD, pulmonary embolism is associated with greater mortality
Cardiovascular surgery
COPD is a common cause of perioperative pulmonary dysfunction in patients
undergoing cardiac surgery
Screening for COPD in this patient population is particularly important because
COPD has been associated with prolonged intubation after cardiac surgery
For patients with preoperative FEV1 <2 L (or <80 percent predicted) or
DLCO <80 percent predicted, the predicted postoperative (PPO) FEV1
and DLCO should be calculated, based upon the preoperative values and
the fractional functional contribution of the lung to be resected.
PPO FEV1 = preoperative FEV1 x (1 y/z)
where y = number of functional or unobstructed lung segments to
be removed, and z = total number of functional segments (typically
19)
COPD and Lung Resection
Cardiopulmonary exercise testing (CPET) is useful when the results of PPO
FEV1, PPO DLCO, and/or low technology exercise testing do not clearly define
the patients risk as either high or low.
Patients who can achieve a VO2 max >20 mL/kg per minute are likely to have
an acceptable rate of postoperative complications, whereas those with a value
<10 mL/kg per min (or less than 35 percent predicted) are probably best
managed by nonsurgical modalities.
For those with VO2 max values in between 10 and 20 mL/kg per minute, the
predicted postoperative (PPO) VO2 max is calculated. If the PPO VO2 max is
<10 mL/kg per min or <35 percent, surgical candidacy is poor and
nonresectional options should be sought. On the other hand, if the PPO VO2
max is 10 mL/kg per min or 35 percent, resection is not absolutely
contraindicated, but the patient must understand the higher risk if either the
PPO FEV1 or DLCO is <30 percent predicted.
Peri-operative Management
General factors include the following.
Every effort should be made to aid with smoking cessation Smoking
cessation at least 4-8 weeks preoperatively is optimal.
Optimization of lung function using inhaled bronchodilators (in
patients with severe COPD can decrease postoperative
complications.
Oral Corticosteroids.