Clinical Management Clinical Management Respiratory DiseasesRespiratory Diseases

Judith Coombes

University of Queensland

Brisbane, Australia

Judith Coombes UQ and PAH

PathologyPathology

• major international cause of morbidity and major international cause of morbidity and mortalitymortality

• In Australia single biggest cause of days In Australia single biggest cause of days lost from worklost from work

• generate largest number of GP visitsgenerate largest number of GP visits

ObjectivesObjectives

• Be able to interpret Spirometry as a lung Be able to interpret Spirometry as a lung function test and monitoring toolfunction test and monitoring tool

• Be able to interpret Peake Expiratory Flow Be able to interpret Peake Expiratory Flow rate (PEFR) as a monitoring toolrate (PEFR) as a monitoring tool

• Understand goals of treatment and be able Understand goals of treatment and be able to communicate pharmaceutical care plan in to communicate pharmaceutical care plan in asthmaasthma

• Understand goals of treatment of and be Understand goals of treatment of and be able to communicate pharmaceutical care able to communicate pharmaceutical care plan in COPDplan in COPD

Not discussing infections, neoplasms or TBNot discussing infections, neoplasms or TB

The LungsThe Lungs

TracheaTracheaBronchus(L&R)BronchiBronchioleAlveoli

Respiratory SymptomsRespiratory Symptoms

• coughcough

• sputum production/haemoptysis sputum production/haemoptysis

• dyspnoeadyspnoea

• wheezingwheezing

• chest/lung painchest/lung pain

Measurement of Measurement of ventilatory functionventilatory function

• Spirometry Spirometry

• PEFRPEFR

• Blood GasBlood Gas

• Exercise test-6 minExercise test-6 min

• chest Xray- normal is asthma and COPDchest Xray- normal is asthma and COPD

SpirometrySpirometry

• SpirometerSpirometer– FVC = Forced Vital CapacityFVC = Forced Vital Capacity– FEV1= Forced Expiratory Volume over 1 FEV1= Forced Expiratory Volume over 1

secondsecond– FEV1/FVC is forced expiratory ratioFEV1/FVC is forced expiratory ratio

• should be >75%should be >75%

• useful for diagnosisuseful for diagnosis• accurately measures degree of impairmentaccurately measures degree of impairment

NormalNormal

PEFRPEFR• Peak Flow MeterPeak Flow Meter

– maximum flow rate which can be forced during an expirationmaximum flow rate which can be forced during an expiration– may differ between metersmay differ between meters– Submaximal effort invalidates readingSubmaximal effort invalidates reading– Not a substitute for spirometryNot a substitute for spirometry– most useful for regular monitoring to detect variationmost useful for regular monitoring to detect variation– warning signswarning signs

• sustained reductionsustained reduction• >20-25% diurnal variation>20-25% diurnal variation

– monitoringmonitoring

Chest X rayChest X ray

• Diagnosis is uncertain (PE, pneumonia, Diagnosis is uncertain (PE, pneumonia, heart failure)heart failure)

• symptoms may not be explained by symptoms may not be explained by asthma or COPDasthma or COPD

• physical evidence of complications-physical evidence of complications-pneumothorax, atelectasis (lung collapse)pneumothorax, atelectasis (lung collapse)

• failure to respond to treatmentfailure to respond to treatment

Blood Gas (arterial)Blood Gas (arterial)

• H+ rises with Pco2H+ rises with Pco2

• In acute hypoventilation CO2 rises and so does In acute hypoventilation CO2 rises and so does H+ causing respiratory acidosisH+ causing respiratory acidosis

• In acute hyperventilation CO2 drops as does H+ In acute hyperventilation CO2 drops as does H+ causing respiratory alkalosiscausing respiratory alkalosis

• (in acute no time for metabolic process so (in acute no time for metabolic process so bicarbonate is not changed)bicarbonate is not changed)

OximetryOximetry

• Measure oxygen saturationMeasure oxygen saturation

• Non invasiveNon invasive

• Light emiting diodesLight emiting diodes

• Expressed as % where normal is 100%Expressed as % where normal is 100%

AsthmaAsthma

• a chronic inflammatory disorder of the airways in which a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils and epithelial cells. In macrophages, neutrophils and epithelial cells. In susceptible individuals this inflammation causes susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness, chest recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly, at night or in the tightness and coughing, particularly, at night or in the early morning. These episodes are usually associated early morning. These episodes are usually associated with widespread but variable airflow obstruction that is with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety the existing bronchial hyperresponsiveness to a variety of stimuli. USA97of stimuli. USA97

Airflow obstruction Airflow obstruction (Excessive airway Narrowing)(Excessive airway Narrowing)

• Smooth muscle hypertrophy and Smooth muscle hypertrophy and hyperplasiahyperplasia

• Inflammatory cell infiltrationInflammatory cell infiltration

• OedemaOedema

• Goblet cell and mucous gland hyperplasiaGoblet cell and mucous gland hyperplasia

• Mucus hypersecretionMucus hypersecretion

• Protein depositionProtein deposition

• Epithelial desquamationEpithelial desquamation

Asthma Diagnosis-1Asthma Diagnosis-1

• No Gold StandardNo Gold Standard– Consensus of respiratory physiciansConsensus of respiratory physicians

• History, physical examination, supportive History, physical examination, supportive diagnostic testingdiagnostic testing

• HistoryHistory– WheezeWheeze– Chest tightnessChest tightness– Shortness of breathShortness of breath– coughcough

Asthma Diagnosis-2Asthma Diagnosis-2

• Physical examinationPhysical examination– Expiratory wheeze suggests asthma (not Expiratory wheeze suggests asthma (not

pathonomonic)pathonomonic)– Absence of physical signs doesn’t exclude Absence of physical signs doesn’t exclude

asthmaasthma– Crackles indicate concurrent or alternate Crackles indicate concurrent or alternate

diagnosisdiagnosis

Asthma diagnosis -3Asthma diagnosis -3

• Diagnostic testing –SpirometryDiagnostic testing –Spirometry

• Pay Attention to techniquePay Attention to technique

– Pre and post bronchodilatorPre and post bronchodilator– Baseline FEV1>1.7L and increase of 12% post Baseline FEV1>1.7L and increase of 12% post

bronchodilator is significantbronchodilator is significant– Or 200ml greater than baselineOr 200ml greater than baseline– Or same rules for FVCOr same rules for FVC

• Also % predicted from tables in the Asthma guidelinesAlso % predicted from tables in the Asthma guidelines

Spirometry for asthma Spirometry for asthma managementmanagement

Assessment of severityAssessment of severity• Severe acute attack <50% predicted or < 1litre Severe acute attack <50% predicted or < 1litre

• Back titration of medicationBack titration of medication• Check symptomatic assessmentCheck symptomatic assessment• Maintain best lung functionMaintain best lung function

AsthmaAsthma

PEFR with asthmaPEFR with asthma

• Diagnosis-not a substitute for spirometryDiagnosis-not a substitute for spirometry– PEF increases >15% with bronchodilatorPEF increases >15% with bronchodilator– PEF in adult varies >20% for 3 days in a week over PEF in adult varies >20% for 3 days in a week over

several weeksseveral weeks

• Severe Acute Severe Acute – <50% predicted or < 100 L/min<50% predicted or < 100 L/min

• Useful for daily home measurementUseful for daily home measurement• Useful in action planUseful in action plan• >80% OK, 60-80% increase preventer, 40-60% >80% OK, 60-80% increase preventer, 40-60%

oral steroids, <40% no relief 000oral steroids, <40% no relief 000

Asthma treatment

National Asthma Council in Australia –

www.nationalasthma.org.au/cms/index.php– Reduce mortality &morbidity of asthma

• Education• Patient self monitoring• Appropriate drug therapy• Regular medical review• Written asthma action plan

Asthma management

• Acute asthma management– Treatment depends on severity

• Mild, moderate, life threatening• Requires emergency care• Hospital admission

• Long term asthma management-chronic• Minimise symptoms and need for reliever• No exacerbations• No limitation on physical activity• Normal Lung Function

Asthma Management

• Medications to treat bronchospasm– ACUTE– RELEIVERS

• Short acting ß2-adrenergic agonists eg salbutamol

terbutaline• Anticholinergic eg ipratropium

Relievers

Asthma Management

• Medications to treat bronchospasm– Chronic– SYMPTOM CONTROLLER

• Inhaled long acting ß2-adrenergic agonists eg salmeterol

• Also use– Theophylline

– Oral ß2-adrenergic agonists (salbutamol syrup)

Asthma Management

• Medications to treat inflamationPREVENTERS

Inhaled sodium cromoglycate

Inhaled nedocromil sodium

Inhaled cortocosteroids eg beclomethasone

Oral corticosteroids eg prednisolone

Leukotrienne receptor antagonists eg montelukast

Beclomethasone dipropionate

Asthma Action plans

• Developed by doctor with patient

• Added role for pharmacist to give advice to patient

• Individualised Action for Deterioration in asthma– ↑ in frequency, severity of symptoms– ↑ use of bronchdilator– Drop in peak flow

Misuse of Home Nebulizers High Among Inner-City Children with Asthma

October 25, 2006 (Salt Lake City)A study of asthma-related deaths among inner-city children and young adults shows that only about half use their home nebulizers as prescribed and rarely have an asthma actionplan to manage disease exacerbations, or if they do have a written plan in the home, they rarely use it.

The findings were presented here yesterday at CHEST 2006, the 72nd annual meeting of the American College of Chest Physicians.

COPDCOPD

• smoking is major cause but smoking is major cause but susceptibility is variablesusceptibility is variable

• directly related to exposure to tobacco directly related to exposure to tobacco smoke smoke – pack years=cigarettes/day x years of pack years=cigarettes/day x years of

smoking /20smoking /20

• relatively fixed airway obstruction with relatively fixed airway obstruction with minimal reversibility from minimal reversibility from bronchodilatorsbronchodilators

COPDCOPD

• Chronic bronchitis- productive cough for >3 Chronic bronchitis- productive cough for >3 months in 2 successive yearsmonths in 2 successive years

• emphysema-abnormal permanent emphysema-abnormal permanent enlargement of air-spaces distal to terminal enlargement of air-spaces distal to terminal bronchioles caused by destruction of bronchioles caused by destruction of alveolar walls.alveolar walls.

• Most have a combination of bothMost have a combination of both• Elderly with reversibility has all 3Elderly with reversibility has all 3

COPD = shaded bitCOPD = shaded bit

Diagnosis of COPDDiagnosis of COPD

• symptomssymptoms– breathlessness doesn’t occur until obstruction is advanced breathlessness doesn’t occur until obstruction is advanced

(unless intercurrent infection)(unless intercurrent infection)

• physical examinationphysical examination– little until disease is severe-over inflated chestlittle until disease is severe-over inflated chest

• chest x rayschest x rays– over inflation, enlarged heart, bullaeover inflation, enlarged heart, bullae

• spirometryspirometry– mild check FEV1/FVC<75%mild check FEV1/FVC<75%– moderate check FEV1 % of predictedmoderate check FEV1 % of predicted

COPDCOPD

Show ceases smoking figureShow ceases smoking figure

ProgressionProgression

Severity Symptoms Treatment

Mild FEV1<80

Smokers cough Little breathlessness Not known to GP

Cease smoking, Antibiotics, Occasional bronchodilator

Moderate FEV1<60

Breathlessness on moderate exertion, hypoxaemic, sputum, known to GP

Bronchodilators, trial of steroids

Severe FEV1<50

Breathlessness on any exertion, some hypercapnic, known to hospital

Flu vaccine, pulmonary rehabilitation, assess for LTOT

COPD Management

– Acute exacerbations– Bronchodilators– Oxygen– Corticosteroids– Antibiotics

– Long term treatment- chronic– Stop smoking– Bronchodilators– Corticosteroids– Immunisation-Pneumonia and flu– Pulmonary rehabilitation

BronchiectasisBronchiectasis

defined as dilation of the bronchi-defined as dilation of the bronchi-

• bronchial walls become inflamed, bronchial walls become inflamed, thickened and irreversibly damaged.thickened and irreversibly damaged.

• Mucociliary transport is impaired-bacterial Mucociliary transport is impaired-bacterial infectionsinfections

• cough productive of sputumcough productive of sputum

Cystic FibrosisCystic Fibrosis

• dysfunction of exocrine glands -abnormal dysfunction of exocrine glands -abnormal mucus productionmucus production– recurrent bronchopulmonary infectionrecurrent bronchopulmonary infection– finger clubbingfinger clubbing– haemoptysishaemoptysis

Interstitial lung disease Interstitial lung disease

• heterogeneous group involving alveolar heterogeneous group involving alveolar walls and peri alveolar tissuewalls and peri alveolar tissue

• insidious onset, chronic disease insidious onset, chronic disease

• inflammatory process probably initiated by inflammatory process probably initiated by an antigenan antigen

• eventual interstitial fibrosis will cause a eventual interstitial fibrosis will cause a restrictive patternrestrictive pattern

RestrictiveRestrictive

Severe Obstructive Sleep Severe Obstructive Sleep ApnoeaApnoea

• 2% women , 4% men2% women , 4% men• Recurrent episodes of airway occlusion in Recurrent episodes of airway occlusion in

sleepsleep– ApnoeaApnoea– ArousalArousal– Daytime sleepinessDaytime sleepiness– Increased CO2Increased CO2

– Sleep labSleep lab– Weight loss, CPAPWeight loss, CPAP