英文精品课件chronic obstructive pulmonary disease （35p）

CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL PRACTICE GUIDELINES REVIEW WEEK 1: DIAGNOSIS AMBULATORY INTERNAL MEDICINE GROUP PRACTICE UNIVERSITY HEALTH NETWORK / MSH SEPTEMBER 2007 Prepared by: Dr. D. Panisko COPD: Guidelines for this Seminar o Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Celli BR et al. Eur Respir J 2004; 23: 932-46. Full document, with updates, available at: , accessed Sept 2007 o Canadian Thoracic Society recommendations for the management of chronic obstructive pulmonary disease - 2003. ODonnell DE et al. Can Respir J 2003; 10(SupplA): 11A- 33A o Global Initiative for Chronic Obstructive Lung Disease. (GOLD). A collaborative of the NIH and WHO. Updated Nov 2006, accessed Sept 2007. Available at COPD Diagnosis: Objectives o After this seminar you should: n be aware of diagnostic clinical practice guidelines for stable chronic COPD n be able to define COPD and asthma and outline a differential diagnosis n be able list important historical and laboratory diagnostic features of COPD n be able to describe the evidence-based physical examination for COPD and airflow limitation COPD I: DIAGNOSIS CASE: A 61 year old man comes to your clinic as a new patient. He had just been admitted to hospital for his first exacerbation of COPD. He has completed a 10 day antibiotic course and 10 days of oral Prednisone. He is now only on an ipratropium puffer, 2 puffs qid. o How is COPD defined ? What is emphysema ? What is asthma ? o Why is it important to make a diagnosis of COPD (as opposed to asthma) in this patient ? COPD I: DIAGNOSIS o COPD Definition: o A preventable and treatable disease state characterized by airflow limitation that is not fully reversible. o The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. o Although COPD affects the lungs, it also produces significant systemic consequences. o Implies post bronchodilator FEV1/FVC 80% predicted Stage II: Moderate FEV1/FVC 9 seconds: A, 4.8 o Subxiphoid Apical Impulse: B, 4.6 o Pulsus Paradoxus 15mmHg: C, 3.7 o Decreased Breath Sounds: B, 3.7 o Forced Expiratory Time 6 - 9 seconds: A, 2.7 * Many other signs not systematically evaluated (diaphragmatic levels, pursed lip breathing, use of accessory muscles, indrawing) COPD I: DIAGNOSIS o Straus et als important contributions to the literature have shown that a single physical sign is not as useful as a combination of historical and physical findings to make a diagnosis of COPD o They have published two models What maneuvre is being performed ? COPD I: DIAGNOSIS Combined history/physical exam Model I: Smoking 40 P.Y. (LR 8.3) Self reported history of COPD (LR 7.3) Maximum laryngeal height (LR 2.8) Age 45 years (LR 1.3) Combined all 4: +LR 220 Combined patients with none: -LR 0.13 COPD I: DIAGNOSIS Combined history/physical exam Model II: *Forced Exp Time 9 sec (LR 6.7) Multivariate: (LR 4.6) *Self reported history of COPD (LR 5.6) (LR 4.4) *Wheezing (LR 4.0) (LR 2.9) Smoked longer than 40 pack years (LR 3.3) Male gender (LR 1.6) Age over 65 years (LR 1.6) *Combined all 3: +LR 59.0 *Combined patients with none: -LR 0.3 COPD I: DIAGNOSIS CASE (cont.): o Physical examination of our patient was only relevant for a barrel chest, diffuse occasional audible wheezes, and a forced expiratory time of 7 seconds. Laryngeal height was 5 cm. o There were no signs of cor pulmonale. o Otherwise, the exam was unremarkable. COPD I: DIAGNOSIS CASE (cont.): o Which of the following investigations are currently indicated ? o How will they help in the care of this patient ? in the care of other patients with stable COPD ? n Spirometry n Full Pulmonary Function Tests n CXR n Helical CT of chest n Allergy testing n O2 saturation (rest, exercise, sleep) n ABG COPD I: DIAGNOSIS o Spirometry: Performed for diagnosis, prognosis, monitoring of therapy. FEV1, FVC, and ratio most important; peak flows not recommended. o Pulmonary Function Tests: Full PFTs not necessary for routine dx, usually performed at the time of initial dx to establish baseline, may be useful for dxdx - i.e to obtain bronchodilator reversibility testing to asses for asthma. o CXR: Useful in exacerbations and for its r/o value for other dxdx. Has low sens. and spec. for the dx of emphysema, thus not recommended by guidelines. COPD I: DIAGNOSIS o Helical CT of Chest: Not necessary for routine diagnosis, may be useful for dxdx or for lung volume reduction OR. o Allergy Testing: May have use in asthma, not COPD. o O2 Sat: In severe COPD (stage 2b or 3) useful to guide O2 therapy. Nocturnal desaturations are probably under diagnosed. o ABG: Needed to guide long term oxygen therapy and to obtain government funding for same. (See guidelines for actual criteria for initiation of treatment will be discussed next week). COPD I: DIAGNOSIS CASE (cont.): o The current Canadian guidelines: n do not emphasize evidence based diagnosis for patients with COPD n put more emphasis on evaluation of impairment, disability with exercise testing, dyspnea assessment scales, and quality of life assessment scales n do not give specific recommendations on how or at what point in the patients course these evaluations should be used COPD: other useful references: o 2 recent review series on COPD: n 5 article se