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Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

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Page 1: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Chronic Obstructive Pulmonary Disease and Asthma:

All That Wheezes?

Clifford Courville, MDPulmonary, Allergy, and Critical Care

Page 2: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Outline

• Introduction and Overview• Asthma– Diagnosis and Treatment

• Chronic Obstructive Pulmonary Disease (COPD)– Diagnosis and Treatment

Page 3: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Our Airways

NHLBI Website

Page 4: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Why Asthma Makes It Harder to Breathe

Page 5: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

www.iowatracs.us

Page 6: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Asthma Guidelines

• Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program

Page 7: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Asthma Definitions

• Chronic inflammation of airways

• Airflow obstruction that is REVERSIBLE? (variable) and recurrent

– Bronchial hyperresponsiveness– Structural changes in airways– Inflammation (neutrophils, eosinophils, mast cells,

etc.)– Atopy (allergic, IgE)

Page 8: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

EPR 3 Guidelines on Asthma 2007 Update

Page 9: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care
Page 10: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Asthma Clinical Symptoms

• Recurrent episodes of wheezing (bronchospasm)

• Breathlessness• Cough (particularly at night)• Chest Tightness

Page 11: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Asthma Diagnosis

• History and Exam

• Pulmonary Function Testing

• Peak Flow Measurements

• Methacholine Challenge Testing

Page 12: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Peak Flow Testing

Page 13: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Asthma Therapy• Avoidance of Triggers (tobacco smoke, perfumes, dust mites, etc.)

• Bronchodilators– Albuterol

• Inhaled Corticosteroids

• Leukotriene Inhibitors (i.e. Montelukast/Singulair)

• Anti-IgE Therapy (Xolair)

• Oral Steroids (Prednisone)

Page 14: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Influence of Tobacco Smoke• Active smoking increases risk for development of asthma

• Children of smoking mothers are 2.1 times more likely to develop asthma

Weitzman et al. Pediatrics. 1990

• Even prenatal exposure to cigarette smokeCunningham et al. Am J Respir Crit Care Med. 1996

• Smoking worsens pre-existing asthmaSiroux et al. Eur Respir J.

2000

Page 15: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care
Page 16: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care
Page 17: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Goals of Therapy• Freedom from frequent or troublesome symptoms of

asthma (cough, chest tightness, wheezing, or shortness of breath)

• Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms

• Few night-time awakenings (<2 nights per month) due to asthma

• Optimization of lung function• Maintenance of normal daily activities, including work or

school attendance and participation in athletics and exercise

• Satisfaction with asthma care on the part of patients and families

Page 18: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Newest Advanced Therapies for Asthma

• Bronchial Thermoplasty

• Immunotherapy (mepolizumab)

Page 19: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Chronic Obstructive Pulmonary Disease

• “a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.” - GOLD Guideline

• 3rd Leading Cause of Death in the US

Page 20: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

CODP is often Confused with Asthma

Page 21: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

COPD – What is the defect?

• Airflow Limitation– Inflammation, mucus, scarring of airways– Reduction in number of airways– Floppiness of airways

• Emphysema – Destruction of alveoli and respiratory bronchiole

• Pulmonary blood vessels– Thickening and loss of small blood vessels

Page 22: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

NHLBI

Page 23: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

What causes COPD?

Page 24: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

COPD - Symptoms

• Shortness of breath (particularly with exercise)

• Cough (commonly productive of sputum)

• Recurrent Bronchitis (exacerbations)– Wheezing, sputum production, chest tightness

Page 25: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Evaluation

• Pulmonary Function Testing

• Gene Testing

• Chest xray or CT scan optional

Page 26: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

COPD Treatment

• Smoking Cessation!!

• Bronchodilators (hand-held inhalers or nebulizers)– Tiotropium is best example

• Inhaled corticosteroids

• Roflumilast

• Macrolide antibiotics (i.e. azithromycin)

Page 27: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

COPD Advanced Therapies

• Oxygen

• Nocturnal Ventilation (BIPAP)

• Lung Volume Reduction Therapy

Page 28: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

COPD Management Goals

• Improve Quality of Life– Improve Walk Distance

• Minimize Exacerbations (Bronchitis episodes)

• Maintain Lung Function

• Improve Longevity

Page 29: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Alternative Diagnoses• Cough and Wheeze– Gastroesophageal Reflux Disease– Post-infectious Cough Syndrome– ACE inhibitor induced Cough– Vocal cord dysfunction– Post nasal Drip/Upper Airway Cough Syndrome– Bronchiolitis/Infections

• Shortness of Breath– Heart Failure– Pulmonary Embolism

Page 30: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Conclusion• Wheezing, cough and shortness of breath may be

presenting features of asthma or COPD.

• Confirmation of the diagnosis of asthma and COPD is important as treatment and prognosis of both differ, and it is important to distinguish these from other serious conditions.

• Smoking cessation is key to prevention and treatment of both conditions.

Page 31: Chronic Obstructive Pulmonary Disease and Asthma: All That Wheezes? Clifford Courville, MD Pulmonary, Allergy, and Critical Care

Thank you.