TOC | Pulm

Chronic Obstructive Diseases of the Lung  (COPD)         COPD2010.pdf     

See also http://copd.acponline.org |  Asthma | Bronchitis | copd2007.pdf | copd2007_rx.pdf   REF:  Best Dx/ Best Rx 2006

Definition/Key Clinical Features  |  Differential Diagnosis  | Best Tests  | Best Therapy  | Best References  
Definition/Key Clinical Features
  • Partially reversible airflow obstruction caused by chronic bronchitis and/or emphysema

Predominant Chronic Bronchitis ("Blue Bloater")

  • History of cigarette smoking
  • Chronic productive cough
  • Frequent chest infections
  • Wheezing
  • Orthopnea
  • Signs of right heart failure

Predominant Emphysema ("Pink Puffer")

  • Dyspnea
  • Weight loss
  • Hyperinflated lung fields

    

Differential Diagnosis
  • Bronchiolitis obliterans
  • Asthma
  • Emphysema caused by ±1-antitrypsin deficiency
  • Bullous lung disease
  • Bronchiectasis
  • Cystic fibrosis
  • Primary ciliary dyskinesia

    

Best Tests

Pulmonary Function Tests

  • Should be performed in all smokers with any respiratory symptoms and all smokers > 45 yr
  • Spirometry shows reduction in FEV1/FVC and FEV1
  • Total lung capacity normal or increased
  • Arterial blood gases
    • Chronic bronchitis: markedly reduced Pao2; increased Paco2; normal diffusing capacity of lung for CO (DLCO)
    • Emphysema: mildly reduced Pao2; normal or decreased Paco2; decreased DLCO

Chest X-ray

  • Chronic bronchitis: normal or increased bronchovascular markings at the lung bases
  • Emphysema: arterial deficiency in lung periphery; hyperinflation; bullous disease

Computed Tomography

  • CT of the chest can show upper lobe emphysema in patients without abnormalities in pulmonary function

    

Nonpharmacologic Therapy
  • Smoking cessation
  • For chronic hypoxia, supplemental oxygen, 15–24 hr/day, sufficient to maintain > 90% arterial oxygen saturation
    • For patients with Pao2 d 55 mm Hg
    • For patients with Pao2 d 59 mm Hg and peripheral edema, hematocrit 55%, or P pulmonale on ECG
  • Influenza and pneumococcal vaccine
  • Physical training increases exercise capacity even in patients with advanced disease
  • Respiratory muscle training with an inspiratory resistor can improve endurance
  • Intermittent application of negative pressure or noninvasive positive pressure ventilation at night can improve daytime symptoms

    

Pharmacologic Therapy     See also  copdRx2009.pdf    

Bronchodilators: can produce 10% increase in maximal expiratory airflow

  • Inhaled long-acting anticholinergics: first-line therapy
    • Tiotropium/Spiriva , DPI (dry-powder inhaler), 18 µg/capsule
      • Maintenance dose: 1 capsule q. day; Cost/mo: $115
      • Exacerbation dose: not recommended
  • Inhaled short-acting anticholinergics
    • Ipratropium bromide/Atrovent
      • Nebulizer, 0.25 mg/ml; may mix with albuterol in same nebulizer
        • Maintenance dose: 0.5 mg q. 6 hr
        • Exacerbation dose: 0.5 mg q. 2–8 hr
      • MDI (metered-dose inhaler), 18 µg/puff: as effective as nebulizer when used with spacer
        • Maintenance dose: 2–6 puffs q. 6 hr;  Cost/mo: $215
        • Exacerbation dose: 3–8 puffs q. 3–4 h;  Cost/mo: $392
  • Inhaled long-acting beta2 agonists (should be used for maintenance therapy)
    • Salmeterol/Serevent: slower onset of action than short-acting beta2 agonists
      • MDI, 21 µg/puff
        • Maintenance dose: 2 puffs q. 12 hr
        • Exacerbation dose: not recommended
      • DPI, 50 µg/blister
        • Maintenance dose: 1 blister q. 12 hr;  Cost/mo: $80
        • Exacerbation dose: not recommended
    • Formoterol/Foradil: faster onset of action than salmeterol
      • DPI, 12 µg/capsule
        • Maintenance dose: 1 capsule q. 12 hr; Cost/mo: $80
        • Exacerbation dose: not recommended
  • Inhaled short-acting beta2 agonists: second-line therapy
    • Albuterol/Ventolin/Proventil  
      • Nebulizer, 5 mg/ml: dilute aerosols to minimum of 4 ml at gas flow of 6–8 L/min
        • Maintenance dose: 1.25–5.0 mg q. 4–8 hr p.r.n.
        • Exacerbation dose: 5.0 mg q. 2 hr
      • MDI, 84 µg/puff: as effective as nebulizer when used with spacer
        • Maintenance dose: 2–4 puffs q. 6 hr p.r.n.; Cost/mo: $34
        • Exacerbation dose: 3–8 puffs q. 2 hr ; Cost/mo: $202
        • DPI, 200 µg/capsule
          • Maintenance dose: 1–2 capsules q. 6 hr p.r.n.
          • Exacerbation dose: not studied in exacerbations
    • Bitolterol/Tornalate
      • Nebulizer, 2 mg/ml
        • Maintenance dose: 0.5–3.5 q. 4–8 hr p.r.n.
        • Exacerbation dose: not studied in exacerbations
      • MDI, 370 µg/puff
        • Maintenance dose: 2–4 puffs q. 6 hr p.r.n.
        • Exacerbation dose: not studied in exacerbations
    • Pirbuterol/Maxair:
      • MDI, 200 µg/puff
      • Maintenance dose: 2–4 puffs q. 6 hr p.r.n. ; Cost/mo: $96
      • Exacerbation dose: not studied in exacerbations
  • Combined short-acting beta2 agonist and anticholinergic (when both are indicated)
    • Albuterol + ipratropium bromide/Atrovent, MDI: albuterol, 90 µg/puff; ipratropium bromide, 18 µg/puff
      • Maintenance dose: 2–4 puffs q. 6 hr p.r.n.; Cost/mo: $140
      • Exacerbation dose: 3–8 puffs q. 2 hr; Cost/mo: $801

Oral Corticosteroids            

  • Should be avoided except for acute exacerbations
  • Should be given in the lowest possible dose, preferably on alternate days
  • Complications of prolonged therapy: weight gain, osteoporosis, hypertension, diabetes, cataracts, myopathy

Inhaled Corticosteroids

  • For patients who have recurrent attacks of wheezing
  • For patients who have significant acute response to inhaled bronchodilators (> 20% increase in FEV1)
  • For patients who have sputum eosinophilia
  • Medium to high doses may be more effective than lower doses
  • May carry a small risk for cataracts

Inhaled Corticosteroids for COPD         

  • Beclomethasone/QVAR: third-highest potency
    • Low dosage: 168–504 µg (42 µg/puff: 4–12 puffs/day; 84 µg/puff: 2–6 puffs/day)   Cost/mo: 42 µg/puff: $146
    • Medium dosage: 504–840 µg (42 µg/puff: 12–20 puffs/day; 84 µg/puff: 6–10 puffs/day)   Cost/mo: 42 µg/puff: $240
    • High dosage: > 840 µg (42 µg/puff: > 20 puffs/day; 84 µg/puff: > 10 puffs/day)   Cost/mo: 42 µg/puff: > $240
  • Budesonide/Pulmicort: second-highest potency
    • Low dosage: 200–400 µg (200 µg/puff: 1–2 inhalations/day)   Cost/mo: $41
    • Medium dosage: 400– 600 µg (200 µg/puff: 2– 3 inhalations/day)   Cost/mo: $55
    • High dosage: > 600 µg (200 µg/puff: > 3 inhalations/day)   Cost/mo: > $55
  • Flunisolide/Aerobid: lowest potency
    • Low dosage: 500–1,000 µg (250 µg/puff: 2–4 puffs/day)   Cost/mo: $22
    • Medium dosage: 1,000–2,000 µg (250 µg/puff: 4–8 puffs/day)   Cost/mo: $46
    • High dosage: > 2,000 µg (250 µg/puff: > 8 puffs/day)   Cost/mo: > $46
  • Fluticasone/Flovent: highest potency
    • Low dosage: 88–264 µg (44 µg/puff: 2–6 puffs/day; 110 µg/puff: 1–2 puffs/day; 220 µg/puff: 1 puff/day)  
      Cost/mo: 44 µg/puff: $85; 110 µg/puff: $38; 220 µg/puff: $29
    • Medium dosage: 264–660 µg (44 µg/puff: 6–15 puffs/day; 110 µg/puff: 2–6 puffs/day; 220 µg/puff: 1–2 puffs/day)
      • Cost/mo: 44 µg/puff: $227; 110 µg/puff: $108; 220 µg/puff: $58
    • High dosage: > 660 µg (44 µg/puff: > 15 puffs/day; 110 µg/puff: > 6 puffs/day; 220 µg/puff: > 3 puffs/day)
      • Cost/mo: 44 µg/puff: > $227; 110 µg/puff: > $108; 220 µg/puff: > $87
  • Triamcinolone/Azmacort: lowest potency
    • Low dosage: 400–1,000 µg (100 µg/puff: 4–10 puffs/day)   Cost/mo: $152
    • Medium dosage: 1,000–2,000 µg (100 µg/puff: 10–20 puffs/day)   Cost/mo: $213
    • High dosage: > 2,000 µg (100 µg/puff: > 20 puffs/day)   Cost/mo: > $213

Diuretics/Vasodilators

  • For patients with far advanced airflow obstruction who have cor pulmonale and right heart failure
  • Diuretics can be used for symptomatic relief of peripheral edema, with care to avoid chloride depletion from long-term use of diuretics
  • Arterial vasodilators, including hydralazine and nifedipine, can reduce pulmonary arterial hypertension but may not produce sustained symptomatic improvement or prolonged survival
    • There is risk of systemic hypotension and renal hypoperfusion
    • Long-term supplemental oxygen is more effective than drugs to reduce pulmonary arterial resistance

    

Surgical Therapy
  • Lung volume reduction surgery
    • Can improve exercise capacity in some patients
    • Can improve survival in patients with upper lobe emphysema and low exercise capacity after rehabilitation
  • Lung transplantation
    • An option for younger patients with advanced chronic airflow obstruction (single-lung transplantation for patients with emphysema, bilateral for those with chronic bronchitis)
    • Five-year survival after lung transplantation is 57%

Best References
  • Calverley PM, et al: Lancet 362:1053, 2003
  • Calverley PM: Eur Respir J 47(suppl):26s, 2003
  • Celli BR, et al: Eur Respir J 23:932, 2004
  • Fabbri LM, et al: Eur Respir J 22:1, 2003
  • Stoller JK: N Engl J Med 346:988, 2002

    

          2009