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Morning report

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Ruhail Kohli

on 26 April 2013

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Transcript of Morning report

Case details At baseline, able to walk around the house
Now having difficulty even going to restroom
Has to stop for a couple of minutes to catch breath
Also has a dry cough for a week
Subjective fever, did not measure Case 58 years old AA gentleman coming to the ED from home

CC : Increasing shortness of breath and difficulty coping at home Overview of the talk Case details
Audience discussion
Didactics
Quiz Case details Physical Examination BP 140/90, HR 95, RR 25, SpO2 92% 2L, T 37.5
General: Alert, looks unwell
Head: PERRLA, EOMI, MMM
Neck: No LAD, no JVD. No thyromegaly, no bruits
CV: S1 and S2, tachycardic, no murmurs,rubs,gallops
Chest: Using accessory muscles, tachypneic, good chest expansion, normal to percussion, good air entry bilaterally, expiratory wheezing throughout
Abdomen: Soft, non tender, no masses/organomegaly, bowel sounds normal
Extremities: trace edema, peripheral pulses present Differential Diagnoses Ruhail Kohli Morning Report No sick contacts
Slight rhinorrhea, no sinus tenderness
Also having headaches and feeling extremely fatigued
Denies any history of CAD, no CP, palpitations this time
No orthopnea, PND, slight lower extremity edema
Similar episode last year, given nebs and Abx in OSH ED and discharged Respiratory Cardiac Other Influenza
Bronchitis
COPD
Asthma
Pneumonia Pneumothorax
ILD
Pulmonary HTN
PE
Malignancy
URI ACS
CHF
Arrhythmia GERD
Obesity
Panic attacks Tests Labs Imaging 4 Hb 13.8, Hct 44.8, WBC 9,Plt 150
Trop T <0.01, CKMB 6.8, BNP 73
Influenza A, B, RSV neg by PCR
Blood Cx, Urine Cx, UA neg
Procalcitonin <0.05
ABG: 7.36/87/77/47 COPD Other Hx Past medical hx significant for DM, HTN, anxiety, heroin use
No surgeries
Family hx: not significant
Social: Lives at home by himself, independent in ADLs, ex smoker, on methadone Rx Patient has a history of COPD
Treated as COPD exacerbation
CXR, UA, UCx, Blood Cx, Influenza panel
Started on IV solumedrol 60mg q8h
Vancomycin, Zosyn and Azithromycin (?HAP)
Albuterol 2.5mg nebs QID
Atrovent 0.5mg nebs QID COPD Defined as airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles and gases Pathology Chronic inflammation in response to irritant, goblet cell increase, mucus gland hyperplasia, fibrosis and narrowing of the small airways

In emphysema, there is airway wall destruction due to loss of tethering causing airway collapse

In chronic bronchitis, there is mucus gland hyperplasia, goblet cell increase, increase in CD8+ T lymphocytes, neutrophils and CD68+ monocytes and macrophages Staging Risk factors Cigarette smoke (>80% COPD patients)

Usually >10-15 pack years

Exposure to environmental antigens, organic and inorganic dust (~20%)

Genetics (A1AT and Emphysema) Chronic Bronchitis Emphysema ROS Home meds Percocet 5/10mg q6h prn, Norvasc 10mg daily, Lisinopril 5mg daily, Zoloft 100mg daily, Methadone 40mg daily, Combivent 2 puffs 3-4 times daily General: fever, malaise
GI: negative for n/v, dysphagia, diarrhea, constipation, hematochezia
CV: No CP, palpitations, dizziness, orthopnea, PND, syncope
GU: No dysuria, hematuria, nocturia
MSK: back pain, no rashes
Hematology: No increased bleeding,bruising, LAD
Endocrine: No cold/heat intolerance, polyuria, polydipsia, goiter
Neuro: No HA, syncope, paralysis, seizures or tremors CXR normal COPD Cardiac EF of 61%
LV systolic function normal
Stage 1 diastolic dysfunction
RV function normal Chronic Bronchitis Chronic productive cough for 3 months in successive 2 years when other causes of cough have been excluded Emphysema Abnormal and permanent enlargement of the airspace distal to the terminal bronchioles accompanied by destruction of the airspace walls without obvious fibrosis Mortality BODE index used to assess mortality
Uses FEV1 post bronchodilator (0-3 points)
6 minute walk test (0-3 points)
MMRC dyspnea scale (0-3 points)
BMI (0-1 points)
0-2 points 80% 4 year survival
3-4 points 67% 4 year survival
5-6 points 57% 4 year survival
7-10 points 18% 4 year survival Management LA anticholinergic: Decrease exacerbations, admissions, resp failure
LABA dec exacerbation by 15%, dec FEV1 decline
LABA + inh steroids: ? dec mortality
Tiotropium + inh steroids + LABA: inc FEV1, dec admissions
Inhaled steroids: 20% dec in exacerbation if FEV1<2L, slow decline in FEV1, more with combined BA, no change in mortality alone, may increase PNA (not budesonide)
Mucolytics: no change in FEV1 but ?dec exacerbations
Oxygen: Indicated for severe COPD if PaO2<55mmHg or SaO2<89% anytime for >5 minutes, prevents cor pulmonale and decrease mortality
15 hours a day (MRC trial)
Other: All stages should include pulmonary rehab, influenza and Pneumovax, smoking cessation (50% decrease in lung function decline, dec mortality)
Others include surgery, PDE-4 inhibitors, BiPAP, Lung transplant Oxygen Therapy Multiple trials have shown Long Term Oxygen Therapy (LTOT) has been shown to reduce mortality in severe COPD
Improved survival likely due to change in pulmonary hemodynamics
Also improved quality of life
2 important trials in 1980's evaluated the use of supplemental oxygen therapy in COPD
The Nocturnal Oxygen Therapy Trial in the US compared continuous O2 use vs 12h oxygen use
The MRC trial in the UK compared the use of nocturnal O2 (15 hours) vs no oxygen in patients with severe COPD Nocturnal Oxygen Therapy Trial (NOTT) 6 centers, 203 patients
Compared the use of nocturnal oxygen (12h, n=102) vs continuous oxygen (24h, n=101)
Follow up at least 12 months, mean follow up of 19.3 months
Inclusion and exclusion criteria included:
NOTT 1043 patients screened, 203 included, majority excluded did not meet stabilization criteria
Hypoxemia main criteria, established twice at least a week apart over 3 week period
O2 administered by Nasal prongs at 1 to 4L/min to keep PaO2 of 60 to 80mmHg
Also used standard rx with beta-2 agonists and theophylline
Close follow up, monitored compliance
Baseline characteristics pretty similar in treatment vs control group NOTT MRC trial 87 patients under 70 years of age with CB or emphysema
Inclusion criteria included severe COPD, FEV1 of <1.2L/min, PaO2 between 40 and 60mmHg and one or more recorded episodes of CHF
FEV1 had to be stable in 2 measurements at least 3 weeks apart
Patients randomised to no no oxygen therapy vs oxygen therapy by NC for 15h daily at 2L/min
Follow up over 3 year period
Treated vs controls well matched
Showed 19 out of 42 in rx group died in 5 years vs. 30 out of 45 controls
Survival advantage among men did not emerge till >500 days
In men, mortality similar between 0-500 days but then risk of death was 12% in treated vs 29% untreated, also statistically significant in women (p<0.05)
Overall improvement in mortality in treatment group vs no treatment (Peto OR 0.42, 95% CI 0.18 to 0.98) MRC results Cochrane Metanalysis Conclusion LTOT has been shown to improve mortality in patients with COPD and severe hypoxemia
LTOT did not show a mortality benefit in patient with mild to moderate hypoxemia or only nocturnal hypoxemia
LTOT should be used if the patient has PaO2 < or equal to 55mmHg or SaO2<88%
LTOT should be considered if PaO2<59mmHg or SaO2<89% if cor pulmonale, RHF or Hct>55%
Generally, if oxygen saturation <88% for >5 minutes during rest/sleep/activity
At least 15 hours of therapy recommended References Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging, UpToDate
Management of stable chronic obstructive pulmonary disease, UpToDate
Management of acute exacerbations of chronic obstructive pulmonary disease, UpToDate
Management of infection in acute exacerbations of chronic obstructive pulmonary disease, UpToDate
Long-term supplemental oxygen therapy, UpToDate
COPD, Pocket Medicine, MGH Handbook of Internal Medicine
Pocket guide to COPD diagnosis, management and prevention, Global Initiative for Chronic Obstructive Lung Disease
Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Annals of Internal Medicine 1980;93(3):391-8.
Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981;1:681-5.
Cranston JM, Crockett A, Moss J, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001744. DOI: 10.1002/14651858.CD001744.pub2
Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care, NICE clinical guidelines
Images courtesy of UpToDate, NLM NIH and Encyclopedia Britannica COPD Chronic Bronchitis Emphysema Quiz Which one of these is true of COPD? Which of the following is true: Quiz The important symptoms of COPD exacerbation include: Quiz Regarding long term O2 therapy Quiz LTOT should be considered in: Emphysema is defined by destruction of airways distal to main stem bronchus
Chronic bronchitis is defined as productive cough most days for 3 weeks in 2 month period
COPD is diagnosed by clinical symptoms PLUS spirometry suggestive of obstructive lung disease
It is characterised by FEV1/FVC of <0.70 pre bronchodilator Quiz 80% of smokers develop COPD if they smoke >5 pack years
A1AT homozygous mutation decreases risk of emphysema
GOLD staging assesses the severity of COPD
BODE index is a tool to assess response to therapy Increasing dyspnea
Increase in the amount of sputum production
Change in characteristic of sputum
All of the above Has been shown to decrease mortality in severe COPD
Equally effective 12 hours vs 24 hours a day
Has been shown to cause multiple side effects
Effective for mild to moderate COPD Patients saturating >92% on room air
PaO2<55mmHg or SaO2<88%
Pre-bronchodilator FEV1/FVC<0.70
Patients with more than 2 COPD exacerbations 12 month mortality was 20.6% in nocturnal vs 11.9% in continuous
24 month mortality was 40.8% in nocturnal and 22.4% in continuous
Overall mortality was 31.5% for all patients
Relative risk of death for nocturnal vs continuous was 1.94(95% CI 1.17 to 3.24)
Significant decrease in mortality in continuous with PaCO2>43mmHg (p value 0.002), pH<7.4 (p value 0.004) Looked at 6 studies including NOTT and MRC
At 12 months, the OR for reducing mortality was 0.53 (95% CI 0.25 - 1.11) for continuous vs. nocturnal (NOTT)
At 24 months, the OR for reducing mortality was 0.45 (95% CI 0.25-0.81) for continuous vs norcturnal (NOTT)
For oxygen vs no oxygen therapy, at 60 months, OR was 0.42 (OR 0.18-0.98) (MRC)
For MRC, the NNT is 4.5, absolute risk reduction is 0.22
For change in FEV1, after 500 days, continuous O2 vs. no oxygen had OR of 0.08 (95% CI 0.04-0.12) (MRC)
Comparison of LTOT in mild-moderate hypoxemia for continuous vs no oxygen did not show a statistical advantage OR 1.39 (95% CI 0.74-2.59)
In mild to moderate hypoxemia, comparison of >15h vs <15h O2 was not statistically significant OR 1.67 (95% CI 0.62-4.47) NICE guidelines Recommends LTOT if PaO2 <7.3kPa (55mmHg) when stable or if PaO2 between 7.3kPa (55mmHg) and 8.0kPa (60mmHg) when stable AND one of secondary polycythemia, nighttime saturation <90% more than 30% time, pulmonary hypertension or peripheral edema
Recommends at least 15 hours of LTOT, benefits greater if >20 hours
Assessment should be considered in patients with FEV1<30% (consider in 30-49%), cyanosis, polycythemia, edema, JVD or saturating <92% RA
Assessment on 2 occasions, at least 3 weeks apart in stable patients receiving optimal medical treatment
Patients receiving LTOT should be reviewed at least once a year
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