Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (27 page)

•
Bronchodilators
(
first-line therapy
):
anticholinergics
, β
₂
-agonists (BA), theophylline

Long-acting (LA) anticholinergic (LAA, tiotropium): ↓ exac., ↓ admit, ↓ resp failure (
NEJM
2008;359:1543), better than ipratropium or LABA as mono Rx (
NEJM
2011;364:1093)

LABA: ~15% ↓ in exacerbations, ↓ FEV
₁
decline, trend toward ↓ mort. (
NEJM
2007;356:775)

LABA + inh steroid: ? ↓ mort. (
NEJM
2007;356:775;
AJRCCM
2008;177:19)

LAA + LABA + inh steroid: ↑ FEV
₁
, ↓ COPD admits (
Annals
2007;146:545)

•
Corticosteroids
(inhaled, ICS): ~20% ↓ in exacerb if FEV
₁
<2.0 L (
Chest
2009;136:1029) may slow ↓ FEV
₁
, but more so in combo with LABA (
NEJM
2007;356:775); ↑ in PNA (not seen w/ budesonide;
Lancet
2009;374:712); no Δ in mort. w/ ICS alone (
NEJM
2007;356:775)

• Antibiotics: daily azithro ↓ exacerb, but not yet routine (
NEJM
2011;365:689 & 2012;367:340)

• Mucolytics: no Δ FEV
₁
, but ? ↓ exacerbation rate (
Lancet
2008;371:2013)

•
Oxygen
: if P
_a
O
₂
≤55 mmHg or S
_a
O
₂
≤89% (during rest, exercise or sleep) to prevent cor pulmonale; only Rx proven to ↓ mortality (
Annals
1980;93:391;
Lancet
1981;i:681)

•
Prevention
: Flu/Pneumovax; smoking cessation (eg, varenicline, bupropion) → 50% ↓ in lung function decline (
AJRCCM
2002;166:675) and ↓ long-term mortality (
Annals
2005;142:223)

• Rehabilitation: ↓ dyspnea and fatigue, ↑ exercise tolerance, ↓ QoL (
NEJM
2009;360:1329)

• Experimental

Lung volume reduction surgery: ↑ exer. capacity, ↓ mort.
if
FEV
₁
>20%, upper-lobe, low exer. capacity (
NEJM
2003;348:2059); bronchoscopic w/ endobronchial valves w/ mixed benefits: ↑ lung fxn but ↑ PNA, exacerb, hemoptysis (
NEJM
2010;363:1233)

Roflumilast (PDE-4 inhibitor): ↑ FEV
₁
when added to standard Rx (
Lancet
2009;374:685&695)

Nocturnal BiPAP: may improve survival, ? decrease QoL (
Thorax
2009;64:561)

• Lung transplant: ↑ QoL and ↓ sx (
Lancet
1998;351:24), ? survival benefit (
Am J Transplant
2009;9:1640)

Staging and prognosis

•
FEV
₁
: 50–80% predicted → 3-y mort. ~11%; 30–50% → ~15%; <30% → ~24%

•
BODE
10-pt scale (
Lancet
2009;374:704); HR 1.62 for resp mort., 1.34 mort. for each 1-pt ↑
B
MI: ≤21 (+1)

O
bstruction (FEV
₁
): 50–64% (+1), 36–49% (+2), ≤35% (+3)

D
yspnea (MMRC scale): walking level (+1), after 100 yd (+2), with ADL (+3)

E
xs capacity (6-min walk): 250–349 m (+1), 150–249 (+2), ≤149 (+3)

superior to FEV
₁
(
NEJM
2004;350:1005); can predict survival from LVRS (
Chest
2006;129:873)

• mMRC score: ≥2 defined as walking slowly b/c breathlessness or having to stop to catch breath walking level

• Ratio of diam PA/aorta >1 associated with ~3× ↑ risk of exacerbations (
NEJM
2012;367:913)

EXACERBATION

HEMOPTYSIS

Definition and pathophysiology

• Expectoration of blood or blood-streaked sputum •
Massive hemoptysis
: ~>600 mL/24–48 h; gas exchange more important than blood loss • Massive hemoptysis usually from tortuous or invaded
bronchial arteries

Diagnostic workup

• Localize bleeding site

Rule out GI or ENT source
by exam, history; may require endoscopy

Pulmonary source: determine whether
unilateral or bilateral, localized or diffuse, parenchymal or airway
by CXR or chest CT, bronchoscopy if necessary

• PT, PTT, CBC to rule out
coagulopathy
• Sputum culture/stain for bacteria, fungi and AFB; cytology to
r/o malignancy
• ANCA, anti-GBM, urinalysis to ✓ for
vasculitis
or
pulmonary-renal syndrome
Treatment

• Mechanism of death is asphyxiation not exsanguination; maintain gas exchange, reverse coagulation and treat underlying condition; cough supp. may ↑ risk of asphyxiation • Massive hemoptysis: put bleeding side dependent; selectively intubate nl lung if needed
Angiography:
Dx & Rx (vascular occlusion balloons or
selective embol of bronchial art
)
Rigid bronchoscopy:
allows more interventional options (electrocautery, laser) than flex. Surgical resection

BRONCHIECTASIS

Definition and epidemiology
(
NEJM
2002;346:1383)

• Obstructive airways disease of bronchi and bronchioles, chronic transmural inflamm w/ airway dilatation and thickening, collapsibility, mucus plugging w/ impaired clearance • Frequency:
>
; in the U.S. more frequent in Asian Americans (
Chest
2012;142:432)
Initial workup

• H&P: cough, dyspnea, copious sputum production, ± hemoptysis, inspiratory “squeaks”

• CXR: scattered or focal; rings of bronchial cuffing; “tram track” of dilated, thick airways • PFTs: obstructive pattern • Chest CT: dilation and thickening of airways; ± cystic changes, infiltrates, adenopathy

Treatment

• Treat underlying condition; mucolytics & bronchodilators • Antibiotics: CF Pts often have multiple drug-resistant organisms (
Pseudomonas
,
Burkholderia cepacia
,
S. aureus
) and require IV antibiotics during exacerbations. Azithro shown to ↓ exacerb. in non-CF bronchiectasis (
Lancet
2012;380:660;
JAMA
2013;309:1251).

• Emerging data on gene-based targeted therapies in CF (
NEJM
2011;365:1663)

SOLITARY PULMONARY NODULE

Principles

• Definition: single, <3 cm, surrounded by normal lung, no LAN or pleural effusion • Often “incidentalomas,” esp with ↑ CT use, but may still be early, curable malignancy