Chronic Obstructive Pulmonary Disease

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 Pathology 6 Clinical-manifestations 7 Laboratory 8 Diagnostic-procedures 9 Radiology 10 Differential-diagnosis 11 Management 12 More General Terms 13 Additional Terms 14 References

More Specific Terms

• chronic bronchitis
• COPD exacerbation
• pulmonary emphysema

Introduction

• Patients with COPD often fall into 1 of 2 classes: Emphysema ( pink puffers) or bronchitis ( blue bloaters).

Etiology

• chronic exposure to airway irritants

• smoking
• environmental/ occupational exposures

• acute exacerbations (see COPD exacerbation)

Epidemiology

• onset in midlife
• 12% of never- smokers > 40 years of age

Pathology

• obstruction to airflow
• airway collapse during expiration

• increased intrathoracic airway pressure during expiration
• loss of elastic recoil of lungs
• leads to air trapping & hyperinflation

• bronchospasm

• increased bronchomotor tone in smooth muscles of airway
• mediators: vagus nerve, extrinsic allergens, cytokine release, external & physical chemical injury, airway hypothermia

• mucosal inflammation & edema
• mucus gland hypertrophy & mucus plugging

Clinical-manifestations

• dyspnea [16]

• persistent & progressive
• generally worse with exercise
• described by patient 'incresed effort to breathe' 'heaviness' 'air hunger' 'gasping'
• respiratory failure may occur

• fatigue
• chronic bronchitis

• chronic cough
• chronic sputum production [16]

• sputum may be increased with exacerbations

• purse-lip breathing & other manifestations of emphysema
• does not fluctuate much over a period of several months*

• * distinguishing feature from asthma

Laboratory

• arterial blood gas ( ABG) if FEV1 < 50% predicted

• hypercarbia over baseline
• pH < 7.30
• carboxyhemoglobin level to identify continued smoking

• serum alpha-1 antitrypsin

• caucasian & < 45 years of age [16]
• absence of risk factors ( smoking, occupational dust)
• basilar lung predominance of emphysema

Diagnostic-procedures

• pulmonary function testing:

• obstructive pattern

• FEV1, FEV1/ FVC & FEF[25-75], measures of expiratory airflow are diminished
• post bronchodilator FEV1 < 80% of predicted
• FEV1/ FVC < 70% of predicted
• when the FEV1 falls below 1 liter, 5 year survival is 50%

• response to bronchodilators is generally poor (in contrast to asthma)
• USPSTF recommends against screening for COPD with spirometry

• echocardiogram: { pulmonary hypertension & cor pulmonale}

Radiology

• chest X-ray ( heart failure, tuberculosis ...) [16]
• radionuclide ventriculography { pulmonary hypertension}

Differential-diagnosis

• (other obstructive pulmonary diseases)
• asthma (fluctuating course)
• cystic fibrosis (early age of onset)
• bronchiolitis obliterans
• bronchiectasis
• tuberculosis [16]
• congestive heart failure [16]
• upper airway obstruction

Management

• manage acute exacerbations: (see COPD exacerbation)
• long term

• smoking cessation*

• nicotine patch or bupropion

• bronchodilators

• may be used in symptomatic patients with FEV1 < 80% of predicted (stage 1) [27]
• long-acting bronchodilator indicated for moderate to severe COPD [31]
• anticholinergic agents

• ipratropium ( Atrovent) MDI, short-acting
• tiotropium ( Spiriva) MDI long-acting

• attenuates symptoms in moderate COPD but does not slow progression
• effective in early-moderate COPD [17]
• tiotropium superior to salmeterol [22]
• initial use of tiotropium vs salmeterol results in higher mortality (14%) [26]

• do not use ipratropium & tiotropium in combination [3]

• beta2-adrenergic agonist

• short-acting inhaled beta2 agonist as needed; albuterol MDI PRN
• long-acting inhaled beta2 agonist MDI ( formoterol, salmeterol) if using albuterol on a regular basis [3]
• long-acting beta2-adrenergic agonist may offer survival advantage in elderly [24]

• theophylline for nighttime symptoms

• glucocorticoids, inhaled steroids ( MDI) controversial (add at stage 3, see stages of COPD) [16]

• decrease in exacerbations offset by increase risk of pneumonia [11]
• high-dose Advair may diminish exacerbation [11]
• Advair might improve survival relative to tiopropium, but no difference in exacerbations, & more pneumonia [11]
• use of fluticasone may increase mortality, budesonide may not increase mortality due to shorter 1/2life [16]
• may increase risk of bone fractures [28]

• ensure proper use of MDI before changing medications
• oxygen*

• severe hypoxemia at rest [27] (stage 3 or 4)
• room air pO2 < 55 mm Hg
• pO2 55-60 mm Hg with signs of tissue hypoxia

• polycythemia
• pulmonary hypertension
• right heart failure ( cor pulmonale)

• nocturnal SaO2 < 88%
• exercise pO2 < 55 mm Hg or SaO2 < 88%

• room air (2 L/min by nasal cannula) or presumably blown on face via a fan relieves dyspnea in normoxemic patients with COPD [30]
• combination therapies

• insufficient evidence to recommend when combination therapy should be chosen over monotherapy [27]
• combined use of long-acting beta2 agonist ( formoterol) + long-acting anticholinergic ( tiotropium) is better than either agent alone [3,10]
• combined use of high-dose inhaled glucocorticoid ( fluticasone) + long-acting beta2 agonist ( salmeterol) is better than either agent alone [3,6] at cost of increased risk of pneumonia [18]
• triple combination therapy reduces mortality [32]

• inhaled glucocorticoid
• long-acting beta2 agonist
• tiotropium

• continue albuterol inhaler for rescue with combination therapies

• long-term azithromycin 250 mg/day may reduce risk of COPD exacerbation [29]
• beta-blockers not contradindicated (see comorbidities)
• regular use of antitussives contraindicated in stable COPD [16]
• surgery

• lung volume reduction
• surgery for GERD

• patient education

• action plan consisting of

• patients receiving prescriptions for short courses of

• prednisone
• antibiotics

• patient taught to recognize symptoms that should prompt initiation of prednisone & antibiotics

• action plans can cut hospitalization in 1/2 [21]

• end stage disease:

• opiates: codeine 30-60 mg every 6 hours

• pulmonary hypertension & cor pulmonale

• optimize bronchodilators
• provide oxygen therapy
• phlebotomy when hematocrit > 50% despite oxygen therapy in presence of CNS compromise
• diuretics are contraindicated; may preciptitate metabolic alkalosis
• vasodilators: not indicated

• general rehabilitation

• exercise program, nutritonal counseling
• pulmonary rehabilitation

• improves quality of life, but not survival [3]
• consider for symptomatic, exercise-limited patients regardless of FEV1 [27]

• vaccination

• influenza yearly
• pneumococcal vaccine

• if >= 65 years of age or FEV1 < 40% predicted [16]
• all COPD patients [3]

• psychoactive drugs

• buspirone ( anxiolytic usually well tolerated, but with delayed (several weeks) onset of action)
• doxepin 25-100 mg/day agent of choice for agitated depression (may have mild bronchodilator effect)
• protriptyline 20 mg QHS, non-sedating tricyclic antidepressant improves diurnal & nocturnal hypoxemia in patients with COPD

• alpha-1 antitrypsin inhibitor in patients with documented alpha-1 antitrypsin deficiency (< 11 um/L) FEV1 (30-60% of normal), non-smoking. Prolastin 60 mg/kg IV weekly
• prognosis: see BODE index
• treatments found to be of no benefit

• N-acetylcysteine 600 mg QD of no benefit (see BRONCUS study)
• self-management [33]

• comorbities:

• beta-blockers may reduce mortality & COPD exacerbations in patients with with COPD & cardiovascular disease [19,25]

• * smoking cessation & oxygen have been shown to increase survival; triple combination therapy may also reduce mortality

More General Terms

• obstructive lung disease
• chronic lung disease

Additional Terms

• BODE index
• features of chronic bronchitis vs pulmonary emphysema risk factors for COPD
• stages of COPD

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 242
2. Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
4. Prescriber's Letter 8(5):25 2001
5. Journal Watch 23(6):50, 2003 Lightowler JV et al Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ 326:185, 2003 <PubMed> PMID: [1] <Internet> [2]
   - Babu KS & Chauhan AL Non-invasive ventilation in chronic obstructive pulmonary disease. BMJ 326:177, 2003 <PubMed> PMID: [3] <Internet> [4]
6. Journal Watch 23(8):61-62, 2003 Calverley P et al Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial. Lancet 361:449, 2003 PMID: [5] Rennard SI COPD: treatments benefit patients. Lancet 361:444, 2003 PMID: [6]
7. Journal Watch 23(14):113, 2003 Keenan SP et al Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med 138:861, 2003 PMID: [7]
8. Journal Watch 25(2):19, 2005 Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ. 2004 Nov 20;329(7476):1209. Epub 2004 Oct 25. <PubMed> PMID: [8] <Internet> [9]
9. Journal Watch 25(13):101, 2005 Decramer M, Rutten-van Molken M, Dekhuijzen PN, Troosters T, van Herwaarden C, Pellegrino R, van Schayck CP, Olivieri D, Del Donno M, De Backer W, Lankhorst I, Ardia A. Effects of N-acetylcysteine on outcomes in chronic obstructive pulmonary disease (Bronchitis Randomized on NAC Cost-Utility Study, BRONCUS): a randomised placebo-controlled trial. Lancet. 2005 Apr 30;365(9470):1552-60. PMID: [10]
10. van Noord JA et al, Effects of tiotropium with and without formoterol on airflow obstruction and resting hyperinflation in patients with COPD Chest 2006; 129:509 PMID: [11]
11. Prescriber's Letter 14(4): 2007 High-dose Advair for COPD Detail-Document#: [12] (subscription needed) [13]
    - Prescriber's Letter 15(3): 2008 Advair (Salmeterol/Fluticasone) vs Spiriva (Tiotropium) for COPD Detail-Document#: [14] (subscription needed) [15]
12. Rabe KF et al, Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Car Med 2007, 176:532 PMID: [16]
13. Part I: Diagnosis and Management of Stable COPD [17] Part II: Diagnosis and Management of Acute Exacerbations [18]
    - Updated Guideline Syntheses on COPD Part I [19] Part II [20] (Finnish Medical Society)
14. Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S, Owens DK; for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2007 Nov 6;147(9):633-638. PMID: [21]
15. US Preventive Services Task Force Screening for Chronic Obstructive Pulmonary Disease using spirometry: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Apr 1;148(7):529-34. Epub 2008 Mar 3. <PubMed> PMID: [22] <Internet> [23]
    - Lin K et al, Screening for Chronic Obstructive Pulmonary Disease using spirometry: Summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2008 Apr 1;148(7):535-43. Epub 2008 Mar 3. <PubMed> PMID: [24] <Internet> [25]
16. Sin DD et al Budesonide and the risk of pneumonia: A meta-analysis of individual patient data. Lancet 2009 Aug 29; 374:712 PMID: [26]
    - Welte T. Inhaled corticosteroids in COPD and the risk of pneumonia. Lancet 2009 Aug 29; 374:668. PMID: [27]
17. Decramer M et al. Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT): A prespecified subgroup analysis of a randomised controlled trial. Lancet 2009 Oct 3; 374:1171. PMID: [28]
    - Davies L and Calverley PMA. UPLIFTing care for chronic obstructive pulmonary disease. Lancet 2009 Oct 3; 374:1129. PMID: [29]
18. Rodrigo GJ et al. Safety and efficacy of combined long-acting beta-agonists and inhaled corticosteroids vs long-acting beta-agonists monotherapy for stable COPD: A systematic review. Chest 2009 Oct; 136:1029. PMID: [30]
19. Rutten FH et al beta-Blockers May Reduce Mortality and Risk of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease Arch Intern Med. 2010;170(10):880-887. <PubMed> PMID: [31] <Internet> [32]
    - Sin DD and Man SF A Curious Case of beta-Blockers in Chronic Obstructive Pulmonary Disease Arch Intern Med. 2010;170(10):849-850. <PubMed> PMID: [33] <Internet> [34]
    - Prescriber's Letter 17(7): 2010 Beta-Blockers and Chronic Obstructive Pulmonary Disease (COPD) Detail-Document#: &pb=PRL (subscription needed) [35]
20. COPD (Chronic Obstructive Pulmonary Disease): NIH Institute and Center Resources [36]
    - Chronic Obstructive Pulmonary Disease (COPD) VA/DoD Clinical Practive Guidelines [37]
21. Rice KL et al. Disease management program for chronic obstructive pulmonary disease: A randomized controlled trial. Am J Respir Crit Care Med 2010 Oct 1; 182:890 PMID: [38]
22. Vogelmeier C et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med 2011 Mar 24; 364:1093 PMID: [39]
    - Wedzicha JA. Choice of bronchodilator therapy for patients with COPD. N Engl J Med 2011 Mar 24; 364:1167. PMID: [40]
23. Lamprecht B et al. COPD in never smokers: Results from the population-based Burden of Obstructive Lung Disease Study. Chest 2011 Apr; 139:752. PMID: [41]
24. Gershon A et al Comparison of Inhaled Long-Acting beta-Agonist and Anticholinergic Effectiveness in Older Patients With Chronic Obstructive Pulmonary Disease: A Cohort Study Ann Intern Med. 2011 May 3;154(9):583-92. PMID: [42]
25. Short PM et al Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study BMJ 2011; 342:d2549 <PubMed> PMID: [43] <Internet> [44]
26. Gershon A et al. Comparison of inhaled long-acting beta-agonist and anticholinergic effectiveness in older patients with chronic obstructive pulmonary disease: A cohort study. Ann Intern Med 2011 May 3; 154:583 PMID: [45]
27. Qaseem A et al Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society Annals 0f Internal Medicine 2011 155(3):179-191 <PubMed> PMID: [46] <Internet> [47]
28. Prescriber's Letter 18(8): 2011 Spiriva (Tiotropium) vs Long-Acting Beta-2 Agonists for COPD Detail-Document#: [48] (subscription needed) [49]
29. Prescriber's Letter 18(10): 2011 Azithromycin to Prevent COPD Exacerbations Detail-Document#: [50] (subscription needed) [51]
30. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet 2010; 37(9743):784-793. PMID: [52]
31. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
32. Short PM et al. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting ß-agonist therapy in COPD. Chest 2012 Jan; 141:81. PMID: [53]
33. Bucknall CE et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: Randomised controlled trial. BMJ 2012 Mar 6; 344:e1060. PMID: [54]
34. Global Initiative for Chronic Obstructive Lung Disease (GOLD) [55]
    - Updated guideline synthesis: COPD Part I. Diagnosis and Management [56] [57] [58] includes updated GOLD recommendations.
    - Updated guideline synthesis: COPD Part II. Diagnosis and Management of Acute Exacerbations to include the updated GOLD recommendations. [59] [60] [61]
    - PART III. PULMONARY REHABILITATION [62]
    - CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD): PULMONARY REHABILITATION [63]
    - DIAGNOSIS AND MANAGEMENT OF STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) [64]
35. DIAGNOSIS AND MANAGEMENT OF STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). GUIDELINES COMPARED American College of Physicians (ACP) Global Initiative for Chronic Obstructive Lung Disease (GOLD) Singapore Ministry of Health (SMOH). Chronic obstructive [65]
    - CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD): DIAGNOSIS AND MANAGEMENT OF ACUTE EXACERBATIONS Global Initiative for Chronic Obstructive Lung Disease (GOLD) Singapore Ministry of Health (SMOH) Department of Veterans Affairs, Department of Defense (VA/DoD) [66]
36. National Guideline Clearinghouse
    - COPD management in the long-term care setting ngc-guideline: [67]
    - Chronic obstructive pulmonary disease (COPD). Finnish Medical Society Duodecim ngc-guideline: [68]
    - Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. (Global Initiative for Chronic Obstructive Lung Disease) ngc-guideline: [69]
    - Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. ngc-guideline: [70]
    - Diagnosis and management of chronic obstructive pulmonary disease (COPD). (Institute for Clinical Systems Improvement) ngc-guideline: [71]
    - Chronic obstructive pulmonary disease. Singapore Ministry of Health ngc-guideline: [72]
    - Screening for chronic obstructive pulmonary disease using spirometry: U.S Preventive Services Task Force recommendation statement. ngc-guideline: [73]
    - Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. ngc-guideline: [74]
    - VA/DoD clinical practice guideline for management of outpatient chronic obstructive pulmonary disease. Veterans Health Administration, Management of COPD Working Group ngc-guideline: [75]
    - COPD - Chronic obstructive pulmonary disease. In: Pulmonary (acute & chronic). Work Loss Data Institute ngc-guideline: [76]
    - Chronic obstructive pulmonary disease (COPD) evidence-based nutrition practice guideline. American Dietetic Association (ADA) ngc-guideline: [77]
    - Chronic obstructive pulmonary disease. University of Michigan Health System. ngc-guideline: [78]
    - Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Clinical Guideline Centre for Acute and Chronic Conditions ngc-guideline: [79]
    - (1) Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). (2) Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD) 2010 supplement. Registered Nurses' Association of Ontario (RNAO) ngc-guideline: [80]
37. National Guideline Clearinghouse Guideline syntheses Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management of Acute Exacerbations Global Initiative for Chronic Obstructive Lung Disease (GOLD) University of Michigan Health System (UMHS Department of Veterans Affairs, Department of Defense (VA/DoD). ngc-guideline-synthesis: 34431
    - Chronic Obstructive Pulmonary Disease: Diagnosis and Management of Stable COPD American College of Physicians American College of Chest Physicians American Thoracic Society European Respiratory Society (ACP/ACCP/ATS/ERS) Global Initiative for Chronic Obstructive Lung Disease (GOLD) University of Michigan Health System (UMHS). ngc-guideline-synthesis: 34771
    - Chronic Obstructive Pulmonary Disease (COPD): Pulmonary Rehabilitation American College of Physicians American College of Chest Physicians American Thoracic Society European Respiratory Society (ACP/ACCP/ATS/ERS) Global Initiative for Chronic Obstructive Lung Disease (GOLD) University of Michigan Health System (UMHS) Department of Veterans Affairs ngc-guideline-synthesis: 35091

chronic obstructive pulmonary disease (COPD)