Emphysema + chronic bronchitis
Etiology: tobacco smoke, alpha-1 antitrypsin deficiency, talcosis (from IV drug use).
H&P + Diagnosis
Symptoms: SOB, cough, sputum production?
Risk Factors: Smoking hx, occupational dust, biomass fuel exposure, asthma, childhood infections, prematurity, FHx of chronic lung disease?
Comorbidities: Heart disease, Metabolic syndrome, Osteoporosis, OSA, Depression, Lung cancer, skin wrinkling?
Differential diagnosis.
Diagnostic studies
-Spirometry with a bronchodilator to get FEV1 and FVC; other PFTs as needed.
-CBC, CMP, CXR, Alpha-1 anti-trypsin deficiency. Consider BMP, ECG.
–COPD Staging per GOLD Guidelines.
Assessment
1) Lung function (degree of airflow limitation) using spirometry.
2) Symptom severity: Assess the patient’s COPD symptom severity using the COPD Assessment Test (CAT) or the COPD Control Questionnaire (CCQ).
3) Exacerbation history: Number of past exacerbations helps to predict the risk of future exacerbation.
4) Comorbidities that may be present.
Distinguish b/n Asthma vs. COPD.
Treatment
Non-pharmacologic treatment
Prevention: 1) Smoking cessation; 2) Flu shot annually, 3) pneumococcal vaccination (PCV13 & PPSV23 for all patients ≥ 65 yrs). Flu shot & PNA vaccination each decreases the incidence of LRTIs.
Pulmonary Rehabilitation (Exercise/physical therapy): Will refer to pulmonary rehabilitation as needed as it improves symptoms, quality of life, and physical and emotional participation in everyday activities.
Reduce occupational and environmental exposures
Good nutrition
Pharmacologic treatment.
Drugs per GOLD Criteria.
Assess the inhaler technique regularly.
Oxygen: Will evaluate for long-term oxygen therapy in the future if the patient develops severe resting chronic hypoxemia as it improves survival in that patient population.
Evaluate and treat comorbid conditions.
GERD as it is associated with an increased risk of exacerbations and poorer health status in COPD patients.
—END—-
COPD Pearls and Important Links
- Tools for evaluating symptom severity: 1) COPD Assessment Tool (CAT), 2) Clinical COPD Questionnaire (CCQ)
- Pulmonary rehabilitation “has been shown to be the most effective therapeutic strategy to improve shortness of breath, health status, and exercise tolerance.” GOLD 2017
- Obstructive and Restrictive Lung Diseases.
- Alpha-1 antitrypsin deficiency (AATD) screening. “The WHO recommends that all patients with a diagnosis of COPD should be screened once especially in areas with high AATD prevalence. A low concentration (< 20% normal) is highly suggestive of homozygous deficiency. Family members should also be screened.” GOLD 2017
- “Testing for alpha-1 antitrypsin (AAT) deficiency should be obtained in all symptomatic adults with persistent airflow obstruction on spirometry. Especially suggestive subsets include the presence of emphysema in a young individual (eg, age ≤45 years), emphysema in a nonsmoker or minimal smoker, emphysema characterized by predominantly basilar changes on the chest radiograph, or a family history of emphysema . However, AAT deficiency may be present in a patient with otherwise “typical” COPD. A serum level of AAT below 11 micromol/L (~57 mg/dL by nephelometry) in combination with a severe deficient genotype is diagnostic.” UTD
- Key indicators for considering a diagnosis of COPD and ordering spirometry: Symptoms: SOB, Cough, Sputum production; Risk Factors: Smoking, Biomass fuel exposure, Asthma, Childhood infections, Prematurity, Family History; Comorbidities: Heart disease, Metabolic syndrome, Osteoporosis, OSA, Depression, Lung cancer, skin wrinkling. Consider the diagnosis of COPD and do spirometry if any of these indicators are present. These indicators are not diagnostic by themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Spirometry is needed to establish a diagnosis of COPD.
- Diagnosis of COPD – GOLD 2017 guidelines say, ” The diagnosis of COPD should be considered (and spirometry performed) in any patient who has dyspnea, chronic cough or sputum production, and /or a history of exposure to risk factors for COPD (e.g. smoking hx, occupational dust, indoor biomass smoke, family hx of chronic lung disease, or presence of associated comorbidities.)”
- Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.
- The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy.
- Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently
Resources
www.goldcopd.org
Click to access wms-GOLD-2017-Pocket-Guide-1.pdf
http://goldcopd.org/wp-content/uploads/2016/11/wms-At-A-Glance-2017-FINAL.pdf
Calculator: http://www.thecalculator.co/health/COPD-Stages-by-GOLD-Guidelines-Calculator-908.html
https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-clinical-manifestations-diagnosis-and-staging
pulmccm.org/main/2013/review-articles/new-gold-guidelines-2013-better-than-the-old-gold/
Click to access COPD-Asthma_Phys_Ed_Booklet.pdf
CMAJ : Canadian Medical Association Journal. 2012;184(12):1365-1371. Alpha-1 antitrypsin deficiency: a commonly overlooked cause of lung disease.