10/11/18 Current Approaches to Asthma & COPD Lekshmi Santhosh, M.D. Assistant Professor, Pulm/Critical Care & Hosp Med 10.11.2018 Primary Care Medicine: Principles & Practice Revisiting the Dutch Hypothesis: Back to 1960 Not All OLD Are Equal, But . . . Broad Look at Obstructive Lung Disease (OLD) Host factors Environmental factors Genetics Smoking Allergy Pollution Airway hyperresp. Infection 1
10/11/18 Diagnosis of Asthma & COPD Current Approaches to A 52 year old woman w/ HTN, HLD, obesity , and childhood 1. Introduction asthma is coming in with shortness of breath. She smoked Asthma & COPD 2. Diagnosis of Asthma & COPD for a few years when in college, but otherwise has been a 3. Management of Asthma & COPD non-smoker . Her husband has smoked for the past 30 years 4. What’s New on the Horizon? Roadmap for the Talk and is trying to quit actively. She asks you whether this is her 5. Questions? asthma coming back or whether she has COPD like her husband? Important History Questions Asthma COPD Childhood asthma? Smoking history? Allergies? Asbestos exposure? Triggers? (Pets, enviro?) Exercise tolerance? Nocturnal sx? Quality of life? Exercise-induced? Exacerbation history? 2
10/11/18 Use a Structured Tool ❏ COPD Assessment Test (CAT) ❏ Administer in waiting room ❏ Score directly maps on to GOLD criteria ❏ Helps you Stage & Manage PFTs: Low-Risk and High-Yield! ❏ When to just start empiric tx of asthma or COPD? ❏ “Classic cases” ❏ For everyone else, PFTs are very helpful ❏ Spirometry - FEV1, FVC, FEV1/FVC ratio - with bronchodilator response ❏ Full PFT - Includes TLC & DLCO 3
10/11/18 PFTs FAQs: Decoding the “Interpretation” Section PFTs FAQs: Decoding the “Interpretation” Section Interpretation: Translation: Interpretation: Translation: “The flow-volume loop is curvilinear, Even though they may not meet exact “Symptoms of obstruction may be Even though they may not meet exact suggesting obstruction, but criteria with FEV1/FVC < 70% for worsened when breathing at lower criteria with FEV1/FVC < 70% for otherwise PFTs are normal.” obstruction, the shape suggests they lung volumes due to obesity.” obstruction, the shape suggests that behave like they have mild they have obstructive-like symptoms obstructive lung dz, so you could (wheezing, dyspnea) when breathing treat for mild obstruction. on exertion, which is exaggerated due to obesity. Key Point Key Point Don’t let the bronchodilator reversibility All that wheezes is not asthma...nor overly sway you. COPD pts can have COPD! Keep your ddx very broad and some BD responsiveness, and asthma think outside the [lung] box. pts can show no responsiveness. 4
10/11/18 Common Asthma & COPD Mimics - Can Delay Dx What about Reactive Airways Disease? ❏ Vocal cord dysfunction ❏ Decompensated CHF ❏ Allergic bronchopulmonary ❏ Obesity ❏ Bronchiectasis aspergillosis ❏ Vasculitides such as ❏ Occupational/enviro lung Eosinophilic diseases ❏ Malignancy Granulomatosis with ❏ Interstitial lung disease Polyangiitis Different from Reactive Airways Dysfunction Syndrome - ❏ Infections such as Acute wheezing in response to inhaled irritant Strongyloides Diagnostically, When to Refer? Anytime if: Current ❏ Basic diagnostics are not helpful (PFTs, Chest CT) Approaches to ❏ You need advanced testing (e.g. 1. Introduction Asthma & COPD 2. Diagnosis of Asthma & COPD methacholine/bronchoprovocation testing, exercise 3. Management of Asthma & COPD testing, bronchoscopy, etc.) 4. What’s New on the Horizon? Roadmap for the Talk ❏ You suspect an asthma/COPD mimic 5. Questions? ❏ You just need extra diagnostic help! 5
10/11/18 COPD Management Links Back to Dx: GOLD COPD ABCs LAMA, LABA, Huh? SABA = short-acting beta-agonist SAMA = short-acting musc-agonist LABA = long-acting beta-agonist LAMA = long-acting muscarinic agonist LABA/ICS = LABA + inhaled corticosteroid COPD Management Links Back to Dx: GOLD LAMA or Complex & LABA/ICS or individual! ?Azithro, LAMA/LABA romiflumast, etc. SABA or SAMA LAMA or LABA prn 6
10/11/18 Asthma Step-Up General Principles Asthma Management Links Back to Sx: GINA 7
10/11/18 Key Point Therapeutically, When to Refer? Anytime if: ❏ Severe asthma requiring ICU stay ❏ Uncontrolled asthma despite step-up therapy ICU Admission for asthma and ❏ You are considering omalizumab or other IgE-mediated tx intubation are strong predictors for ❏ You suspect an asthma mimic fatal or near-fatal asthma. These patients can die before they reach the hospital. Key Point Current Approaches to Don’t forget non-pharm management: 1. Introduction Asthma & COPD 2. Diagnosis of Asthma & COPD smoking cessation, pulmonary rehab, 3. Management of Asthma & COPD 4. What’s New on the Horizon? Roadmap for the Talk trigger avoidance, exercise, flu vaccine 5. Questions? & Pneumovax . 8
10/11/18 Targeting the Social Determinants of Asthma NIH Grant: “Social adversities and asthma: A new phenotype?” Dr. Neeta Thakur Targeting the Link Between Obesity & Asthma Using Big Data to Target the Genomics of COPD NIH Grant: “Role of Metabolic Dysfunction, NIH Grant: “Identifying the Th2 endotype in the Gut Microbiome, in Driving Severe COPD: Clinical and Pathological Asthma” Implications” Dr. Stephanie Dr. Michael Peters Christensen 9
10/11/18 Current Thank You! Approaches to 1. Introduction Asthma & COPD 2. Diagnosis of Asthma & COPD Questions? 3. Management of Asthma & COPD 4. What’s New on the Horizon? Roadmap for the Talk 5. Questions? Lekshmi.Santhosh@ucsf.edu @LekshmiMD 10
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