COPD & Asthma

Small Airway Inflammation in Asthma

56 billion dollars each year
Number of suffers grew 15% in past decade.
500,000 hospitalizations
1.9 million ER visits
8.9 m doctor visits
3,388 deaths

There is no cure for asthma.

There is an association between small airway dysfunction and uncontrolled asthma:

- The majority of pts have uncontrolled according to  asthma according to the "2009 Asthma Insight and Management Survey".
- pts overestimate degree of asthma control control
National Guidelines:
- 71% pt were poorly controlled - survey 82% thought they followed docs orders
- Only 46% said were asked about exacerbations at every visit.

- Pathophysiology: 
- Inflammatory ds of the airways involving inflammation of both large and small airways of the lungs. 
- If the pt has a genetic disposition toward asthma have one or more triggers: exercise, weather changes, pollen, dust, tobacco smoke. Asthma suffers can experience symptoms without any known triggers.
 - Inflammation causes airway obstruction, bronchial hyperresponsiveness, and airway remodeling, asthma ds severity. This varies between individuals & over time.

Why do patients with asthma have small airway inflammation:
-  Some have a distinct immunological response called allergies to inhaled "allergens".  
-- The smallest allergens can deposit themselves in the airway tissue. 
-- Inhaled irritants can cause an inflammatory reaction in the airways which is usually eosinophilic.

- What happens in small airways that contribute to sx from mild exacerbations to fatality.
- Patient may sometimes have normal large airway function.
- Large airways can be assessed by flow: FEV1 - these patients may also have uncontrolled asthma based on small airway function. 
- Determined by spirom - the FEF25-75% or "impulse oscillometry". (IOS)
- These small airway measures may correlate more accurately with asthma exacerbation that large airway measures (FEV1).
- Small airway dysfucnt can be worse in pts w/ unstable than stable patient.
- Small aw dysfunction is actually a risk factor asthma exacerbation.
- Must assess sm and lg aw function in patients with asthma.

- Who has sm aw involvement: noct sx, recurrenat exac, exposure to small particle aero-allergens.
- Infl occurs in large and sm airways of pts with asthma.
- Current techniques to assess sm aw fn include - spiro - FEF25-75% is a better meas than FEV1 and correlates better with sx control than FEV1 Another method is Impulse oscilometery - technique uses sound waves to rapidly measure airway changes.
- R5-R20 specifically measures sm aw resistance in the lungs.
- X5 - reactants at 5Hz
- There is a direct relationship beta small aw dysfunction and asthma control.
- FEF25-75%, and aw resistance meas by IOS

- Leave this out: Summarize:
- Mult / single breath nitrolgen washout test.
- NO concentrations in single breath exhaled air.
- High res CT & MRI with inhaled .. gases can also meas sm airways in pts w/ asthma.
- Monitoring small aw fn can predict future exacerbation - IOS helped identify loss of control.
- TX - Foundation - Nat A Prev Prog 2009 - Inh corticos for 

Treatment Options
-  INH corticosteroids are first line therapy for mild to moderate persistent asthma.
- Corticosteroids should reach all sites of inflammation.
- There are differences in inh corticos formulations and delivery devices and there may be differences in which allow some to reach all airways of lung better than others.
-- some inh costicos are suspension aerosols are hetergenous mixtures of solid drug particles in a propellent.
-- some inh corticos are solution aerosols which homogenous of solid drug particles are delivered as the propellent evaporates. When solutions are delivered by MDA inhalers small particles are deposited throughout the bronchiol tree.

1. airway inflammation has sig impact on sm aw lung fn in asthma patients. SAD is ass w/ poor control.
2. Small airway fn should be assessed to understand the efficiacy of tx and future exacerbations and FEF25-75 is more diagnostic than FEV1.
3. Choose a tx that can reach all areas throughout lung.

Diagnose asthma with spirometry and SABA
- FEV 1 increases 12% and 200 ml
- pre-SABA FEV1 < 80% predicted

An elderly COPD pt comes w/ glaucoma & you start Timoptic - watch out for what ? REF

38. A 66-year-old male smoker is being evaluated for a persistent cough and difficulty breathing. 
Spirometry confirms a fixed obstructive pathology with an FEV of about 50% of predicted for 
size and age. His oxygen saturation is 89%–90% on room air. 
Which one of the following would be most effective to prevent worsening of this patient’s 
A) A combined inhaled corticosteroid and long-acting $-agonist 
B) A long-acting anticholinergic agent 
C) Long-term oral corticosteroids 
D) Oxygen therapy 
E) Smoking cessation 

Item 38 
This patient has moderate to severe COPD. Smoking cessation is the single most important therapeutic 
intervention in patients with this condition and should be a priority of care. No existing medications have 
been shown to modify the long-term decline in lung function that is typical of COPD, but smoking cessation 
does prevent this decline. Long-term use of oxygen in COPD patients who also have chronic, severe hypoxia 
(<88% saturation) can improve quality of life and prolong survival; however, oxygen cannot prevent further 
decline in lung function. Long-term use of oral corticosteroids is discouraged because of an unfavorable 
risk-to-benefit ratio. 
Ref: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Medical 
Communication Resources, 2006, pp 8-15. 2) Rabe KF, Beghe B, Luppi F, et al: Update in chronic obstructive pulmonary 
disease 2006. Am J Respir Crit Care Med 2007;175(12):1222-1232.
152. The use of a corticosteroid inhaler in patients with stable chronic obstructive lung disease has 
been shown to 
A) increase the risk for osteoporotic fracture 
B) increase the risk for pneumonia 
C) produce no change in patients’ perceptions of quality of life 
D) reduce overall mortality

Item 152 
COPD is the fourth leading cause of death in the United States. Stopping smoking and the use of 
continuous oxygen, when necessary, are the main interventions that have been shown to lessen overall mortality in this illness. 
The use of corticosteroid inhalers for COPD has received mixed reviews. Studies show an increase in the incidence of pneumonia, which is directly related to the dosage. There are also concerns about the potential for an increase in fractures; however, a meta-analysis of multiple studies has not shown this to be the case. There has been no improvement in overall mortality with the use of the corticosteroidinhalers; nevertheless, on questionnaires patients indicate an improvement in quality of life and fewer bronchitis exacerbations. 
Ref: Drummond MB, Dasenbrook EC, Pitz MW, et al: Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease. JAMA 2008;300(20):2407-2416. 

32. A 56-year-old female has a 35-pack-year smoking history. She is concerned that she may have 
COPD, although she has no history of chronic cough, chest pain, or other pulmonary symptoms. 
Her family history is remarkable for a mother with COPD who was a smoker, but there is no 
family history of "-antitrypsin disease. 
Which one of the following would you recommend with regard to screening spirometry? 
A) Screening, based on her age 
B) Screening, based on her family history 
C) Screening, based on her smoking history 
D) No screening, based on lack of benefit
Item 232 
COPD is the fourth leading cause of death in the United States. The diagnosis is made by documenting 
airflow obstruction in the presence of symptoms and/or risk factors. Airflow limitation cannot be 
accurately predicted by the history and examination. 
The U.S. Preventive Services Task Force recently concluded that there is “moderate certainty” that 
screening asymptomatic patients for COPD using spirometry has little or no benefit and is not 
recommended. This recommendation applies to otherwise healthy individuals without a family history of 
"-antitrypsin disease. 
Ref: US Preventive Services Task Force: Screening for chronic obstructive pulmonary disease using spirometry. Agency for 
Healthcare Research and Quality, 2008.

99. A 69-year-old female presents with postmenopausal bleeding. You consider whether to begin your evaluation with vaginal probe ultrasonography to assess the thickness of her endometrium. 
In evaluating the usefulness of this test to either support or exclude a diagnosis of endometrial cancer, which one of the following statistics is most useful? 
A) Likelihood ratio 
B) Number needed to treat 
C) Prevalence 
D) Incidence 
E) Relative risk
There has been a large increase in the number of diagnostic tests available over the past 20 years. Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. The statistics that are clinically useful for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratios. 
Likelihood ratios indicate how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it. In the example given, if the patient’s endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is £4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%. 
The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. Prevalence is the existence of a disease in the current population, and incidence describes the occurrence of new cases of disease in a population over a defined time period. The relative risk is the risk of an event in the experimental group versus the control group in a clinical trial. 
Ref: Ebell MH: Diagnosis: Making the best use of medical data. Am Fam Physician 2009;79(6):478-480. 

09. A 55-year-old male presents to your office for evaluation of increasing dyspnea with exertion 
over the past 2 weeks. He has smoked 2 packs of cigarettes per day since the age of 20. He has 
had a chronic cough for years, along with daily sputum production. He was given an albuterol 
inhaler for wheezing in the past, which he uses intermittently. On examination he has a severe 
decrease in breath sounds, no evidence of jugular venous distention, no cardiac murmur, and 
no peripheral edema. A chest film shows hyperinflation, but no infiltrates or pleural effusion. 

Office spirometry shows that his FEV is only 55% of the predicted value. 
You consider using inhaled corticosteroids as part of the treatment regimen for this patient. This 
has been shown to 
A) increase cataract formation 
B) increase the incidence of fracture 
C) increase the risk of pneumonia 
D) slow the progression of the disease 
E) improve overall mortality from the disease 
Item 209 
COPD has several symptoms, including poor exercise tolerance, chronic cough, sputum production, 
dyspnea, and signs of right-sided heart failure. The most common etiology is cigarette smoking. A patient 
with any combination of two of these findings, such as a 70-pack-year history of smoking, decreased 
breath sounds, or a history of COPD, likely has airflow obstruction, defined as an FEV £60% of the 
predicted value. In stable COPD, treatment is reserved for patients who have symptoms and airflow 
obstruction. Treatment options for monotherapy are all similar in effectiveness and include long-acting 
inhaled anticholinergics, long-acting $-agonists, and inhaled corticosteroids. 
Inhaled corticosteroids will not reduce mortality or affect long-term progression of COPD. However, they 
do reduce the number of exacerbations and the rate of decline in the quality of life. There appears to be 
no increase in cataract formation or rate of fracture. These agents do have side effects, including candidal 
infection of the oropharynx, hoarseness, and an increased risk of developing pneumonia. 

Ref: Calverley PM, Anderson JA, Celli B, et al; TORCH investigators: Salmeterol and fluticasone propionate and survival in 
chronic obstructive pulmonary disease. N Engl J Med 2007;356(8):775-789. 2) Qaseem A, Snow V, Shekelle P, et al; 
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;147(9):633-638. 3) Yang IA, Fong KM, Sim EH, et al: Inhaled corticosteroids for stable chronic obstructive 
pulmonary disease. Cochrane Database Syst Rev 2007;18(2):CD002991. 4) Drummond MB, Dasenbrook EC, Pitz MW, et al: Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: A systematic review and meta-analysis. JAMA 2008;300(20):2407-2416. 5) Cayley WE Jr: Use of inhaled corticosteroids to treat stable COPD. Am Fam Physician 2008;77(11):1532-1533.

COPD Presentation

What meds are recommended for all 4 stages of COPD ? REF
- LABA (salmeterol & tiotropium) recco for stages II, III and IV.
- Inhaled corticosteroids recco for stages III and IV.
- Mucolytics can be considered for stages III and IV.

At least what percentage of airway reversibility do you need in order to confirm the diagnosis of asthma? 12% REF
End COPD Presenation

I'm pasting straight in because I'm tired.  Will clean up later. Can't believe I got stuffed on a PPD.

The dramatic decrease in the incidence of epiglottitis is the result of routine vaccination with Haemophilus influenzae type b vaccine. REF

Radon is a naturally occurring, inert, radioactive gas which is a decay product of uranium. It can seep from soil beneath homes and reach concentrations in excess of the EPA standard of 4 picocuries. The EPA and the Surgeon General have recommended that all homes be tested for radon levels. Radon abatement measures can reduce radon concentration below EPA thresholds. Epidemiologic studies implicate radon as the second leading cause of lung cancer in the U.S., responsible for up to 30,000 of the 150,000 annual cases of bronchogenic cancer. Risk is heightened by concomitant exposure to tobacco smoke. REF

Question 7 of 10 Which one of the following is consistent with current recommendations?  (check one)
 A. Giving influenza vaccine to all persons age 50 and over 
 B. Giving influenza vaccine to persons under age 65 only if they are at high risk 
 C. Advising all patients to receive influenza vaccine 
 D. Routinely giving pneumococcal vaccine whenever an initial influenza vaccination is given 
Since 1999, the American Academy of Family Physicians (AAFP) has recommended routine influenza vaccination for all persons aged 50 and over. The CDC has also recommended this change from the traditional schedule of beginning routine vaccination at age 65. Recommendations regarding pneumococcal vaccination remain unchanged. Ref: Zimmerman RK: Lowering the age for routine influenza vaccination to 50 years: AAFP leads the nation in influenza vaccine policy. Am Fam Physician 1999;60(7):2061-2070. 2) Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2002:51(RR03):1-31.

Question 3 of 10
A 10-year-old white male is brought to your office with a chief complaint of “head congestion” associated with moderate malaise and a low-grade fever for 7 days. He has had a thick, discolored nasal discharge for the last 2 days. Which one of the following is correct regarding his management?   (check one)
 A. Amoxicillin should be prescribed 
 B. Erythromycin should be prescribed 
 C. No antibiotics should be used at this time 
 D. Sinus radiographs should be ordered, and the decision to use antibiotics should be based on the findings 
Clinical diagnosis of bacterial sinusitis requires the following: prolonged nonspecific upper respiratory signs and symptoms (i.e., rhinosinusitis and cough without improvement for >10–14 days), or more severe upper respiratory tract signs and symptoms (i.e., fever of 39 degrees C or higher, facial swelling, and facial pain). This individual does not meet these criteria, so antibiotics should not be used at this time. Although some believe that mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) indicates the presence of bacterial sinusitis, this sign should be recognized as part of the natural course of a nonspecific, uncomplicated viral upper respiratory infection (URI). Sinus radiographs can demonstrate thickened mucosa, infundibular occlusion, and occasional air-fluid levels in uncomplicated viral URI. Ref: O’Brien KL, Dowell SF, Schwartz B, et al: Acute sinusitis—Principles of judicious use of antimicrobial agents. Pediatrics 1998;101(1 supp):174-177.

Question 9 of 10
A healthy 40-year-old female presents for her annual gynecologic examination. She tells you that she also needs a tuberculin screening test for her anticipated volunteer work at the local hospital. She has had no significant illness or exposures and has been your patient for nearly 20 years. You administer a PPD test which shows 10 mm of induration on the second day. The most appropriate next step in her evaluation would be:   (check one)
 A. A repeat PPD in 2 weeks 
 B. A chest radiograph (two views) 
 C. Screening liver function tests 
 D. Isoniazid (INH) for 9 months for treatment of her latent tuberculosis infection 
In 2000, the American Thoracic Society and the Centers for Disease Control and Prevention (CDC) advocated a shift in focus from screening the general population to testing only patients at increased risk for developing tuberculosis. In some persons PPD reactivity wanes with time but can be recalled by a second skin test administered 1 week or more after the first (i.e., two-step testing). For persons undergoing PPD skin testing, such as health-care workers, initial two-step testing may preclude misclassification of persons with boosted reactions as PPD converters. In those at low risk, such as this patient, a tuberculin skin test is now considered positive only if induration is at least 15 mm. Thus, this hospital volunteer would pose little risk to the hospital population since her 10-mm reaction falls within the guidelines of a negative test. She does not require diagnostic evaluation at this time, and isoniazid therapy is not indicated. Ref: Kasper DL, Braunwald E, Fauci AS, et al (eds): Harrison’s Principles of Internal Medicine, ed 16. McGraw-Hill, 2005, pp 961-966.

Nitrofurantoin can cause chronic interstitial restrictive lung disease. REF

A course of preoperative corticosteroids has been shown to be beneficial for patients with COPD.

PTX - Oxygen lowers the pressure gradient for nitrogen and favors transfer of gas from the pleural space to the capillaries.

Asthma classifications: REF

Anaerobic lung abscesses are most often found in a person predisposed to aspiration who complains of a productive cough associated with fever, anorexia, and weakness. REF

Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year.REF

Smoking, drug and alcohol abuse, improper diet, and inadequate exercise are all greater public health hazards than asbestos. REF

Mild persistent asthma: symptoms occur more than 2 days per week but not daily and use of albuterol more than 2 days per week but not daily. Also sx  < 2  nights per week with FEV1>80 FEV variability 20-30% REF REF

Another asthma classification (it's actually getting simpler): REF
intermittent: 1 exacerbation per week & 1 exac at night per month.
mild persistent: > 2 days for week
moderate persistent: daily
server persistent: throughout the day.

Stepwise approach to treatment: REF
1. daily low-dose inhaled corticosteroid(ex. ..)  or leukotriene receptor antagonist (ex. ..)
2. medium-dose inhaled corticosteroid (ex. ..) or low-dose inhaled corticosteroid plus a long-acting inhaled β-agonist (ex. ...) Fill this in later.

Which medication for reducing respiratory secretions does not cross the BBB ? REF

Youtube Asthma: REF

Sterter vs Stridor in kids REF

Difference between Stridor and Wheezing:

* place holder

Marc Curvin, MD,
Jan 14, 2014, 3:14 PM