Management of Chronic Airflow Obstruction

J.R. Sheller, M.D.

Allergy, Pulmonary & Critical Care Medicine

Chronic Airflow Obstruction

• Asthma

• COPD – emphysema/chronic obstructive bronchitis

• Bronchiectasis – cystic fibrosis

• Obliterative bronchiolitis

• 12.1 million adults ages 25 and older reported being diagnosed with COPD; 21 million asthmatics

• Total estimated cost of COPD $32.1 billion, asthma was $13.8

• COPD is the fourth leading cause of death in the U.S. and is projected to be the third leading cause of death by the year 2020.

• 5000 deaths/yr from asthma

Spirometry

Functional residual capacity

FEV1

(%) max

Time (yrs)80 20 40

100

50

Disability

Death

FEV1

(%)

Time (yrs)80 20 40

100

50

Disability

Death

Smoking Cessation• Counseling

– Has patient thought about stopping?– Rehearse reasons to quit– Offer to help

• Group therapy – quitting sessions Cancer Society, Heart Assoc., Lung Assoc.

• Medications– Wellbutrin– Nicotine– Clonidine

Bronchodilators

• Beta2 adrenergic agonists– By metered dose inhaler– By nebulizer

• Short acting – albuterol, terbutaline – rescue medicine

• Long acting – salmeterol, formoterol– Not used for “rescue”

Anticholinergics

• Ipratropium

• Tiatropium

Work best in COPDViral exacerbations of asthma in children

Theophylline

• Methylxanthines – adenosine antagonists, phosphodiesterase inhibitors, induces histone deactylase

• Narrow therapeutic window• Not important in emergency• May help in difficult cases• Phosphodiesterase 4 inhibitor

Antiinflammatory RX

• Can improve function

• Can improve symptoms

• Uncertain if it alters natural history

• May affect structural changes (remodeling)

Inhaled Corticosteroids

• Topically active

• Delivered to the airway

• First pass liver metabolism reduces systemic availability

• Unknown mechanism of action

Inhaled Corticosteroids

• Theoretical:– suppression of adrenals– growth retardation in kids

• Known: – oral thrush and vocal cord dysfunction– Increased cataracts– Increased loss of bone

• Beclomethasone – 2 puffs QID

• Triamcinalone – 2 inhalations TID

• Fluticasone – 2 inhalations BID (3 strengths)

• Flunisolide – 2 inhalations BID

• Budesonide – 2 inhalations BID

Convenient, cheap

Leukotriene Modifiers

• Zileuton – 5 Lipoxygenase inhibitor• Receptor antagonist

– Zafirlukast 20mg BID– Montelukast 10mg QD

COPD

• 72 year old smoker for 60yrs• Cough, sputum production, dyspnea• FEV1 33% predicted; DLCO 25% predicted• Rhonchi, wheezes, pedal edema

DX: Chronic obstructive bronchitis and emphysema

http://www.goldcopd.com/

COPD Rx

• Smoking cessation• Inhaled ipratropium, beta agonist using MDI• Long acting beta adrenergic - salmeterol• Flu vaccine, pneumovax• Antimicrobials for increased sputum (amoxicillin,

doxycycline, macrolides, trimethoprim/sulfa)• Inhaled corticosteroids controversial • Avoid oral steroids

• Calls with low grade fever, dyspnea, ankle edema

• Admitted to hospital with SaO2 75%

• Oxygen by nasal prongs

• BiPAP (non invasive ventilation)

• Systemic steroids – iv methylprednisolone, convert to oral (60mg prednisone)

• Nebulized ipratropium/albuterol

• Pneumovax, influenza vaccine

Home Oxygen• SaO2 <89% (or pulmonary hypertension,

Hct >55, CHF)

• Should be used 24hrs day

• After 6 weeks, recheck sats (50% of patients no longer need it)

Home oxygen tethers patients, causing deconditioning

Pulmonary rehab, activity are important

• 35 year old female with episodic cough, wheezing, dyspnea after jogging

• Childhood history of asthma• Atopic (hay fever)• Normal exam

• FEV1 normal; FEV1/FVC reduced

• Albuterol MDI prior to exercise• Medication works, but she uses it each

day• Add inhaled steroids• Now awakening at night with cough• Add long acting beta agonist (salmeterol,

formoterol; or combination, eg Advair, Symbicort)

• Rehearse inhaler use, action plan• Allergy/Pulmonary consultation

http://www.nhlbi.nih.gov/about/naepp/

• Still having problems with dyspnea, uses albuterol several times a day

• GERD, Sinus disease

• Increase inhaled steroids

• Add leukotriene modifierMontelukast, zafirlukast – receptor

blockers Zileuton – inhibitor of 5-lipoxygenase

• Consider theophylline

• Anti IgE (omalizumab)

• Has symptoms of URI, using albuterol every 2hrs, not getting relief

• ED Rx

– Oxygen– Continuous albuterol– Intravenous methylprednisolone 125mg– Ipratropium– Mg may help those with most severe obstruction

– Measure PEFR, FEV1, pulsus paradoxus

– Admit in 2hrs if no improvement

Risk of death in Asthma

• Frequent hospitalizations• Intubated for asthma• Poor perception of airflow obstruction• Frequent albuterol rescue medication use• Psychosocial problems

Treatment Scheme

• Mild intermittent -agonists

• Mild persistent + inhaled steroids

• Moderate salmeterol, more inhaled steroids,

leukotriene modifiers

• Severe theophylline, oral steroids, anti IgE