COPD UpdateChronic Obstructive Pulmonary Disease

David Henke MD, MPHN Engl J Med 356;8 Feb. 2007

Kurosawa, H. et al. N Engl J Med 2004;350:1036

Dynamic Narrowing

Diagnosis of COPD

Symptoms

Cough

Sputum

Dyspnea

Exposure to risk factors

Tobacco smoke

Occupation

Indoor/outdoor pollution

SpirometryGOLD Guidelines, 2001.

What Happens To Smokers?Doll-BMJ. 2004 June 26;328(7455):1519

50% of Persistent Smokers Killed By Their Habit - 25% age 35-69

Full Impact On National Mortality Takes > 50 Years To Realize

Smoking Doubles Age Specific Mortality In Middle & Old Age

Longevity Has Improved Rapidly But Not For Smokers

Stopping At 50 Y.O. Halved The Hazard

Stopping At 30 Y.0. Avoided Most Of the Risk

Smokers Die About 10 YRS. Younger

• Combination ICS & Long-acting Beta agonists (LABA) outcome: 18% reduction of all-cause death over 3yrs.

Intention to Rx: 39 pts to save 1 life over 3yrs. P=0.052

• Mono-therapy ICS associated with more pneumonia• No adverse risk with LABA therapy (not powered for

African Americans)• Combination Therapy verses either mono-therapy:

– Better health status– Fewer exacerbations--– Less oral steroids– Protection against declining lung function NEJM 356;8,2007

(Similar results AJRCCM 175 Jan. 2007)

Towards a Revolution in COPD Health (TORCH)

Clinic Patient

65 y.o. white female (60p/y smoker)w/o sx’s . Concerned about smoking, husband insisted she see MD.

Performs ADLs, worked as hostess in son’s restaurant

No SOB/DOE.

Mildly obese/ normal physical

What Do I Tell My Patient With A Concerned Husband Who Denies

Symptoms?

• I Don’t Care If You Have COPD Because You Smoke And If You Have It You Deserve It

• I’ll Give You A Valium Prescription So You Can Sedate Your Hyper-Vigilant Husband

• You May Have COPD Because You Smoke Even Though You’re Not Aware Of Symptoms. The Only Way To Be Sure Is To Perform

Spirometry.

Spirometry

65 y.o. white female (60p/y smoker)w/o sx’s

After Bronchodilator

Pre % Ref Post % Ref 9 months laterFVC 79% 83% (5%) 93%FEV1 51% 57% (12%) 67%FEV1/FVC 49% 53% 55%25-75% 16% 30% (92%) 32%PEFR L/sec 3.67 3.97 home 2.10 4.57 home 3.75

DLCO 13.5 ml/mmHg/min. %Ref 63%

ABG (RA): pH 7.42 CO2= 41 O2=66

% RefTLC 120%FRC (pl) 137%RV 169%

Spirometry

CXR: Hyperinflation

86 y.o. male with 90 py smoking D/Ced 1968 with worsening: CRI (Cr.4.7), chronic diarrhea (?etiology), HTN, s/p CVA, s/p biliary stent.

CC: 7months of progressive DOE; new supplemental O2 need

HPI: Still active and into his business office daily without dyspnea until 7 mos. PTA developed SOB walking from the car to office. Patient now wheelchair dependent and unable to work.

Progressive Dyspnea In COPD

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Spirometry: (PRE) (POST)

FVC 4.15 (101%) 4.37 (106%)

FEV1 2.47 (86%) 2.73 (95%)

FEF25-75 0.93 (50%) 1.54 (82%)

Pulmonary Function Test Case

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Diffusion:

DLCO ml/mmHg/min: 8.1 (35%)

DLCO/Va ml/mmHg/min: 1.51 (45%)

6 min. walk: Sats 80’s%

ABG/RA: pH 7.39 PaO2: 58 mmHg PaCO2: 23 mmHg

High Probability VQ For

Pulmonary Embolus

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Most COPD ptsdie from extra-pulmonary dz,e.g., 25% of severe exacerbationsw/o clear cause& resulting in hospitalizationshad PEs.(Ann Intern Med.2006;144:390)

Summary• Relay on Risk & Spirometry (symptoms) to dx COPD

•Therapeutic cornerstone in smokers with COPD:

Smoking Cessation•Only smoking cessation and maintaining

Hgb sats. > 90% prolong life•Early detection & Rx for COPD can preserve & improve lung function (Combination vs ICS or B-agonist mono-RX: may be the more effective)

•Most COPD patients die from non-pulmonary dz