Name:
A 69-Year-Old with Shortness of Breath
Description:
A 69-Year-Old with Shortness of Breath
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T00H08M34S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to episode 52: A 69-Year-Old with Shortness of Breath.
DR. WIENER: Okay, hi Cathy. So a 69-year-old man with COPD has been admitted to the hospital three times over the past year for COPD exacerbations. Before I go on, let's pause for a second and let's just talk a little bit about COPD.
DR. HANDY: Let's start with definitions. COPD is chronic obstructive pulmonary disease and it's defined as airflow limitation that is not fully reversible. Patients typically have chronic bronchitis that presents with chronic cough and phlegm or emphysema which is from destruction of the lung alveoli or some overlap between the two. The strongest risk factor for COPD is cigarette smoking. You didn't mention that but is he a smoker?
DR. WIENER: So he actually was a smoker, a pretty heavy smoker and he quit about 5 or 10 years ago but despite quitting, he has a daily cough and he has sputum production. His last spirometry which was measured a few months ago, showed an FEV1 of 45% predicted.
DR. HANDY: Those are two important factors that you mentioned. So one is the symptoms and two are the spirometry results. So those two things seen in this patient along with the risk factor which you mentioned a heavy history of smoking are really how we diagnose COPD. So we want to move on to grading of disease and you mentioned the FEV1 of 45%. Now that puts him in the severe category of COPD and I'll go over the GOLD's criteria.
DR. HANDY: So all of this is in patients who have an FEV1 over FVC that's less than 70% so obstructive lung disease. The GOLD criteria have four categories of severity for COPD. Mild is in patients who have an FEV1 over 80% predicted, Mild is in patients who have an FEV1 over 80% predicted, moderate is people who have FEV1 that's 50 to 80% predicted, severe disease as in this patient is when the FEV1 is between 30 and 50% predicted and finally, very severe diseases categorized as those with an FEV1 less than 30% predicted.
DR. WIENER: So you would say that this patient by the GOLD criteria is GOLD level III or severe impairment?
DR. HANDY: Exactly.
DR. WIENER: Okay, well, where does asthma fit into COPD? You didn't mention that at all.
DR. HANDY: There is some overlap in terms of some of the medications and bronchospasm but asthma should be considered a distinct entity since it's episodic, not directly related to cigarette smoking and differs in how we approach prevention and treatment.
DR. WIENER: Okay, back to COPD, I mentioned in the early presentation that he had been admitted to the hospital three times in the past year for COPD exacerbations, let's talk about them for a second.
DR. HANDY: Acute exacerbation of COPD are part of why this disease is so bad because it's the acute exacerbations that are frequent cause of morbidity and mortality in COPD. And they also contribute over 70% of healthcare expenditures for COPD. So also a big problem for the healthcare system. Acute exacerbations are defined as acute or subacute worsening of respiratory symptoms and sometimes the function can be impaired as well. Risk factors for the development of acute exacerbation include the severity of baseline airflow obstruction.
DR. HANDY: So in people who have FEV1 of less than 50%, they're more likely to have acute exacerbations. A history of prior exacerbations and also an elevated ratio of the pulmonary artery to aorta on chest CT.
DR. WIENER: I'm sure that exacerbations are a demand on the healthcare system, you alluded to that before but how big a problem is this?
DR. HANDY: Yeah, so they cost over $10 billion to the healthcare system in the US annually. So determining the causes of exacerbations and also thinking about prevention of future exacerbations have been important targets in the care of COPD patients and a lot of research in the disease. It's also been observed that some patients seem to have what we consider a frequent exacerbation phenotype. And these patients really are at a higher risk of mortality. So trying to prevent exacerbations can have important health benefits obviously but then also economic benefits.
DR. WIENER: What do we know about what precipitates the typical exacerbation?
DR. HANDY: Mostly acute exacerbations are associated with airway inflammation or infection, inquiring a new strain of bacteria or a viral respiratory infection. Therefore, strategies for prevention have been primarily focused on decreasing inflammatory responses and preventing infection. It's important for patients with COPD to receive appropriate vaccinations and be aware of their susceptibility to viral infections.
DR. HANDY: Many patients with COPD are older and can be grandparents with exposures to young kids and we know that young kids can be Petri dishes for respiratory viruses. So that can also be another common source of infection.
DR. WIENER: So let's go back to the question. So as I mentioned before, he previously smoked a pack of cigarettes daily for 50 years but he quit a few years ago. His recent oxygen saturation on room air is 91%. So the question asks, which of the following treatments is most likely to decrease the frequency of his exacerbations? And the options are,
A: doxycycline 100 milligrams three times a week;
B: continuous oxygen at two liters per minute;
C: nocturnal bi-level positive airway pressure or bi-pap with an inspiratory pressure of 18 and an expiratory pressure of 12 centimeters of water; option D is roflumilast, 500 micrograms daily; and option E is theophylline, 300 milligrams daily. What do you think?
DR. HANDY: The answer is D, roflumilast. So roflumilast is the selective phosphodiesterase 4 inhibitor that's been demonstrated to decrease exacerbation frequency and the need for a short course of steroids in individuals with COPD who have symptoms of chronic bronchitis and frequent exacerbations. However, it has limited effects of pulmonary function and chronic respiratory symptoms. It seems to work best for patients with moderate to severe COPD and frequent exacerbations.
DR. HANDY: And the mechanism is not clear but likely involves the anti-inflammatory effects.
DR. WIENER: So that could be a good choice in this patient but what about the other options, why are they not good options?
DR. HANDY: Well, neither bi-level positive airway pressure or bi-pap nor oxygen therapy are specific for exacerbations. They may be used in patients with advanced COPD to correct chronic respiratory failure or hypoxemia. Some studies have shown that theophylline may improve lung function in patients with COPD but it doesn't reduce the frequency of exacerbations.
DR. WIENER: What about doxycycline? That was option A.
DR. HANDY: Yes, so chronic administration of doxycycline has not been shown to reduce the frequency of COPD exacerbations. However, the macrolide antibiotic, azithromycin has both anti-inflammatory and antibiotic properties and there was a large randomized control trial where it was shown to decrease exacerbation frequency and increase the time to first exacerbation when administered at a dose of 250 milligrams daily. So that would have been a good choice but not doxycycline.
DR. WIENER: So are there any other options or other interventions to reduce the frequency of COPD exacerbations that were not mentioned in the question?
DR. HANDY: Yes, so other interventions that decrease exacerbation frequency include inhaled glucocorticoids in individuals with frequent exacerbations or asthmatic symptoms and also the influenza vaccine. Long-acting anticholinergic medications and long-acting beta agonists also decrease exacerbations.
DR. WIENER: Okay, the teaching point here is that in patients with COPD, acute or subacute exacerbations are an important cause of morbidity, mortality and excessive healthcare costs. In patients at risk, there are a number of interventions including the relatively new drug, roflumilast that may decrease the frequency of COPD exacerbations. And I'd like to add in this era of COVID-19, it's very, very important that we protect our patients with COPD because they are at risk of greater severity and greater complications.
DR. HANDY: And you can read more about this in the Harrison's chapter on COPD and I'll also call your attention to the New England Journal of Medicine article on azithromycin for COPD exacerbations which was published in 2011 by Albert et al. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine.
DR. HANDY: Go to accessmedicine.com to learn more.