A COPD Primer PDF
Preview A COPD Primer
Ralph J. Panos, William L. Eschenbacher A COPD Primer Ralph J. Panos, William L. Eschenbacher A COPD Primer Managing Editor: Magdalena Wierzchowiecka Language Editor: Dylan Richards Published by De Gruyter Open Ltd, Warsaw/Berlin Part of Walter de Gruyter GmbH, Berlin/Munich/Boston This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 license, which means that the text may be used for non-commercial purposes, provided credit is given to the author. For details go to http://creativecommons.org/licenses/by-nc-nd/3.0/. © 2015 Ralph J. Panos and chapters’ contributors ISBN: 978-3-11-046800-7 e-ISBN: 978-3-11-046811-3 Bibliographic information published by the Deutsche Nationalbibliothek. The Deutsche National- bibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.dnb.de. Managing Editor: Magdalena Wierzchowiecka Language Editor: Dylan Richards www.degruyteropen.com Cover illustration: is an original work by Mohammad Ahsan Zafar, MD. Contents Preface xvii Ralph J. Panos, MD 1 Introduction and Definition of Chronic Obstructive Pulmonary Disease COPD 1 1.1 Definition of Chronic Obstructive Pulmonary Disease (COPD) 2 1.1.1 Preventable 2 1.1.2 Progressive 2 1.1.3 Treatable 3 1.1.4 Airflow Obstruction That Is Not Reversible [Persistent] 4 1.1.5 Major Point of Confusion: “Reversibility” 4 1.1.6 Inflammation 5 1.1.7 Lung/Pulmonary 6 1.1.8 Exacerbation 6 1.2 Diagnostic Criteria 6 1.3 Staging Disease Severity 7 1.4 COPD Is a Syndrome 8 1.5 Genetic Factors 8 1.6 Clinical Symptoms and Differential Diagnosis 9 1.7 Imaging 10 1.8 Treatment 10 1.9 Conclusion 11 1.10 Summary Points 11 References 11 Ralph J. Panos, MD 2 Epidemiology and Economic Consequences of COPD 14 2.1 Introduction 14 2.2 Epidemiology 15 2.2.1 Risk Factors for COPD Development 15 2.2.1.1 Tobacco Smoke 15 2.2.1.2 Passive or Environmental Tobacco Smoke Exposure 16 2.2.1.3 Non-tobacco Smoke Factors 16 2.2.1.4 Occupational Exposures 16 2.2.1.5 Air Pollution 17 2.2.1.6 Sex 18 2.2.1.7 Infections 18 2.2.2 Prevalence 18 2.2.2.2 United States 19 2.3 Economics 21 2.3.1 Direct Costs 21 2.3.2 Indirect Costs 22 2.3.3 Effect of Treatment 22 2.4 Conclusion 23 2.5 Summary Points 24 References 24 William L. Eschenbacher, MD 3 COPD Recognition and Diagnosis: Approach to the Patient with Respiratory Symptoms 31 3.1 Introduction 31 3.2 Patient Presenting with Respiratory Symptoms 31 3.2.1 Further Discussion of Dyspnea/Shortness of Breath 33 3.3 Initial Screening Evaluation for a Patient Presenting with Respiratory Symptoms Including Dyspnea 35 3.3.1 Exclude Causes of Symptoms Other than Lung Disease 36 3.3.2 Respiratory Causes for Symptoms 36 3.3.2.1 Initial Evaluation of Respiratory Processes 36 3.3.2.2 Further Evaluation of Causes of Respiratory Symptoms After Spirometry Test Results 37 3.4 COPD 38 3.4.1 Definition of COPD 38 3.4.2 Other Diagnostic Tests to Help Confirm the Presence of COPD 40 3.5 Asthma 41 3.6 Interstitial Lung Disease 42 3.7 Summary Points 43 References 43 William L. Eschenbacher, MD 4 Pulmonary Function Testing: Spirometry: Presence and Severity of Airflow Limitation/Obstruction 45 4.1 Introduction 45 4.2 Reasons for Spirometry Testing 46 4.3 Spirometry Screening for COPD 47 4.4 Limitations of Spirometry 47 4.5 Three Phases of a Spirometry Test 48 4.6 Displaying the Results of Spirometry Testing 49 4.7 Acceptability and Repeatability Criteria of Spirometry Testing 51 4.8 Measurements from Spirometry Testing 52 4.9 Patterns of Spirometry Impairment or Limitation 52 4.9.1 Airflow Obstruction Pattern 52 4.9.2 Restrictive Lung Defect Pattern 54 4.9.3 Mixed Impairment with Both Airflow Obstruction and Lung Restriction 54 4.10 Interpretation of Spirometry Results 54 4.10.1 Reference Equations 54 4.10.2 Racial Differences in Reference Equations 58 4.10.3 The Lower Limit of the Normal (LLN) Range 59 4.10.4 What is Considered to Be Abnormal? 60 4.10.5 Determine Predicted Values and % of Predicted Values 60 4.10.6 Interpretation of Spirometry Test Results for Impairment Patterns 60 4.10.7 Airflow Obstruction 60 4.10.7.1 Possible Restrictive Lung Defect 61 4.10.7.2 Mixed Impairment Pattern 62 4.10.7.3 Controversy for Determination of Airflow Limitation/Obstruction 62 4.10.7.4 Bronchodilator Response 63 4.11 Summary Points 64 References 64 William L. Eschenbacher, MD 5 Radiology: Use of Lung Imaging to Help in the Identification of Patients with COPD 66 5.1 Introduction 66 5.2 Chest Radiographs 66 5.3 Computed Tomography (CT) Scans 67 5.3.1 CT Scans and Emphysema 67 5.3.2 CT Scans and Air-trapping 68 5.3.3 CT Evaluation of Airway Changes in COPD 69 5.3.4 CT Scans for COPD Phenotypes 70 5.3.5 Lack of Correlation Between CT Findings and Spirometric Results for COPD 70 5.3.6 CT Scans for Smoking-related Interstitial Lung Diseases 71 5.3.7 Use of Low Dose CT Scans for Surveillance for Lung Cancer 72 5.4 Other Advanced Imaging Techniques in COPD 72 5.4.1 PET Scans 72 5.4.2 MRI Scans 73 5.5 Summary Points 73 References 74 Michael T. Borchers, PhD, Gregory Motz, PhD 6 Pathogenesis of COPD 76 6.1 Introduction 76 6.2 Chronic Bronchitis 77 6.3 Emphysema 77 6.4 Smooth Muscle 77 6.5 Fibrosis 78 6.6 Pathogenesis of COPD 78 6.6.1 Genetics: Gene-association Studies 78 6.6.2 Epigenetics 79 6.6.3 Protease: Antiprotease Imbalance 79 6.6.4 Oxidative Stress 80 6.7 Airway Inflammation in COPD 82 6.7.1 Epithelium 83 6.7.2 Neutrophils 83 6.7.3 Macrophages 84 6.7.4 Eosinophils 84 6.7.5 Mast Cells 85 6.7.6 γδ T Cells 85 6.7.7 Natural Killer (NK) Cells 86 6.7.8 Natural Killer T (NKT) Cells 86 6.7.9 T Cells 87 6.7.10 B Cells 88 6.7.11 Dendritic Cells 89 6.8 Cytokines and Chemokines in COPD 89 6.9 COPD as an Autoimmune Disease 90 6.10 Systemic Inflammation 91 6.10.1 Cardiovascular Disease 91 6.10.2 Nutritional Abnormalities 92 6.10.3 Skeletal Muscle Dysfunction 92 6.10.4 Osteoporosis 93 6.10.5 Neurological Disorders 93 6.11 COPD Exacerbations 93 6.12 Summary Points 94 References 94 Shari Altum, Ph.D., Katherine Butler, Psy.D., Rachel Juran, Psy.D. 7 Smoking Cessation 104 7.1 Introduction 104 7.2 Smoking Risks 105 7.3 Factors Associated with Cessation 105 7.4 Screening Recommendations 106 7.5 Using Physiological Data When Addressing Smoking 110 7.6 How to Present Spirometry Results to Promote Smoking Cessation 110 7.7 Readiness for Change 111 7.7.1 Precontemplation 112 7.7.2 Contemplation 113 7.7.3 Preparation 114 7.7.4 Action 114 7.7.5 Maintenance 115 7.8 The 5 A’s Model 116 7.8.1 Step 1: ASK 116 7.8.2 Step 2: ADVISE 117 7.8.3 Step 3: ASSESS 117 7.8.4 Step 4: ASSIST 117 7.8.5 Step 5: ARRANGE 117 7.9 Motivational Interviewing 121 7.9.1 Clinical Effectiveness of Motivational Interviewing for Treating Tobacco Use Disorder 123 7.9.2 Developing Competency in the Use of Motivational Interviewing 123 7.10 Interventions 123 7.10.1 Nicotine Replacement Therapies and Medications 125 7.11 Other Nicotine Sources 125 7.12 Conclusion 128 7.13 Summary Points 128 References 129 Shari Altum, Ph.D., Rachel Juran, Psy.D., Katherine Butler, Psy.D. 8 Fostering Patient Self-Management of COPD 131 8.1 Introduction 131 8.2 Clinician Skills 131 8.3 Stages of Change 133 8.4 Patient Self-Management Skills 134 8.5 Self-Management Tasks 135 8.5.1 Medication Adherence 136 8.5.2 Exacerbation Action Plans 139 8.5.3 Coping with Breathlessness 140 8.5.4 Exercise 141 8.5.5 Nutrition 142 8.6 Self-Management Programs 142 8.6.1 Pulmonary Rehabilitation 143 8.6.2 Living Well with COPD 144 8.6.3 Chronic Disease Self-Management Program 145 8.7 Shared Decision-Making 146 8.8 End-of-Life Discussions 149 8.9 Integrated Care Teams 150 8.10 Conclusion 150 8.11 Summary Points 153 References 154 Muhammad Ahsan Zafar, MD 9 Natural History, Phenotypes, and Gender Differences in COPD 159 9.1 Natural History of COPD 159 9.2 Factors Influencing Lung Function in COPD 160 9.2.1 Lung Growth and Early Life Events 161 9.2.2 Cigarette Smoking 162 9.2.3 Genetic Susceptibility 163 9.2.4 Advancing Age 163 9.2.5 Emphysema 163 9.2.6 Bronchodilator Responsiveness 164 9.2.7 Early Disease 164 9.2.8 Biomarkers 165 9.3 Role of COPD Exacerbations and Progression of Disease 165 9.3.1 Lung Function Decline 165 9.3.2 Quality of Life 166 9.3.3 Mortality 166 9.3.4 Factors Associated with COPD Exacerbations 166 9.4 COPD Phenotypes 168 9.4.1 Different Phenotypes of COPD 168 9.4.2 Genetic: Alpha 1-antitrypsin Deficiency 168 9.4.2.1 Therapeutic Implications 171 9.4.3 Anatomic: Emphysema-Hyperinflation Phenotype 171 9.4.3.1 Therapeutic Implications 171 9.4.4 Physiologic: Bronchodilator Responsive/COPD-Asthma Overlap Syndrome 172 9.4.4.1 Therapeutic Implications 172 9.4.5 Clinical Frequent Exacerbator 173 9.4.5.1 Therapeutic Implications 173 9.4.6 Clinical: Chronic Bronchitis/Mucous Producer 176 9.4.6.1 Therapeutic Implications 176 9.5 Gender Differences in COPD 176 9.5.1 Reasons for Gender Differences in COPD 177 9.5.1.1 Change in Tobacco Consumption Trend 177 9.5.1.2 Tobacco Susceptibility 177 9.5.1.3 Biologic Differences 177 9.5.2 Epidemiology 178 9.5.3 Clinical Features and Phenotypic Differences 178 9.5.4 Comorbidities 179 9.5.5 Treatment Disparities 179
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