CAT

After completing your assigned readings, can anyone answer the following questions from Chapter 232 in our Hospital Medicine text?

1.     What conditions mimic an acute exacerbation of COPD and require different diagnostic and treatment modalities?

2.     What impatient therapeutic modalities reduce mortality or length of stay for patients with exacerbation of COPD?

3.     What are the indications for noninvasive ventilation for patients with an acute exacerbation of COPD?

4.     Explain the therapeutic interventions that you would consider and discuss with a patient at the time of discharge following an acute exacerbation of COPD?

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CHAPTER 232
Chronic Obstructive Pulmonary Disease

Gerald W. Staton, MD

Christopher D. Ochoa, MD

Key Clinical Questions

What conditions mimic an acute exacerbation of chronic obstructive pulmonary
disease (COPD) and require different diagnostic and treatment modalities?

What inpatient therapeutic modalities reduce mortality or length of stay for
patients with exacerbation of COPD?

What are the indications for noninvasive ventilation for patients with an acute
exacerbation of COPD?

Explain the therapeutic interventions that you would consider and discuss with a
patient at the time of discharge following an acute exacerbation of COPD?

INTRODUCTION
DEFINITION AND BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a group of clinical and pathological
pulmonary disorders that are preventable and treatable and are characterized by airflow

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limitation that is not fully reversible. The most common phenotypes of COPD are
emphysema and chronic bronchitis. Emphysema is generally defined as irreversible
enlargement of the airways and loss of elastic recoil. Clinically, emphysema presents with
dyspnea along with clinical findings of an expanded chest, decreased breath sounds,
radiographic lucency, and flattening of the diaphragms. Chronic bronchitis is defined by
the finding of cough and sputum production on most days of at least 3 months per year
for two consecutive years. Pathologically, the hallmarks of chronic bronchitis are large
airway inflammation and the hypertrophy and hyperplasia of the mucous-secreting goblet
cells. COPD is diagnosed after demonstrating airflow limitation by spirometry (at a time
free of exacerbation) that is not fully reversible in patients who exhibit cough, sputum
production, dyspnea or other appropriate risk factors. The severity of COPD is classified by
the degree of limitation in the forced expiratory volume in 1 second (FEV1) as well as by
the frequency of exacerbations (0-1 vs ≥ 2 per year) and patient reported symptoms using
validated questionnaires (Tables 232-1 and 232-2).

TABLE 232-1 GOLD Spirometry Criteria for Chronic Obstructive Pulmonary Disease
Severity

GOLD Stage Severity Spirometry
I Mild FEV1/FVC < 0.7 and FEV1 80% predicted
II Moderate FEV1/FVC < 0.7 and 50% FEV1 < 80%

predicted
III Severe FEV1/FVC < 0.7 and 30% FEV1 < 50%

predicted
IV Very severe FEV1/FVC < 0.7 and FEV1 < 30% predicted

or
FEV1 < 50% predicted with respiratory
failure or signs of right heart failure

FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; GOLD, Global Initiative for Chronic
Obstructive Lung Disease.

TABLE 232-2 GOLD Grading Criteria for Chronic Obstructive Pulmonary Disease

Grade Sp

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e also vital for improving the patient’s health after discharge and include education
regarding proper inhaler technique, and avoidance of second-hand smoke (and other
respiratory irritants). Patient education regarding the ability to recognize the symptoms of
an exacerbation should be emphasized.

PULMONARY REHABILITATION

Pulmonary rehabilitation is an important part of outpatient COPD care after an admission
for AECOPD, and should be considered at the time of discharge for all patients with
chronic lung disease with the goal of alleviating symptoms and optimizing functional
capacity. Evidence supports that entering pulmonary rehabilitation within 10 days of
hospital discharge is safe. Furthermore, patients enrolled in early pulmonary rehabilitation
experienced improved exercise tolerance and health status at 3 months. Beyond
functional capacity, pulmonary rehabilitation programs often focus on establishing social
support and care networks that are most appropriate for the patient and can have quality-
of-life benefits beyond physical improvements.

PRACTICE POINT

Evidence supports that entering pulmonary rehabilitation within 10 days of hospital
discharge is safe, and patients enrolled in early pulmonary rehabilitation experience
improved exercise tolerance and health status at 3 months.

SURGICAL TREATMENT OPTIONS AND TRANSPLANT EVALUATION

Surgical treatment options for COPD include lung volume reduction surgery (LVRS),
bullectomy, lung transplantation and investigational approaches. LVRS involves bilateral
removal of 25% to 30% of total lung volume. The National Emphysema Treatment Trial,
published in 2003, demonstrated that LVRS improved exercise capacity but not survival
among all patients with severe emphysema. This trial did, however, identify subgroups
that had a survival advantage. The best candidates for LVRS are patients with
predominantly upper-lobe disease and a low exercise capacity after pulmonary
rehabilitation. Bullectomy has not been well studied in randomized trials, but it may be
considered for patients with at least one-third of the thorax occupied by bullae.

For patients with advanced disease another therapy to consider is lung
transplantation. Lung transplant referral is indicated for younger patients with COPD that
have progressive symptoms despite maximal medical therapy, including smoking
cessation. Lung transplant for COPD has been shown to improve quality of life, but effect
on mortality has not been clearly demonstrated and is more controversial. For further
analysis of trials addressing treatment strategies in COPD, please refer to the key
references (Table 232-10).

TABLE 232-10 Evidence-based Medicine: Key References for Chronic Obstructive
Pulmonary Disease

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Reference Methodology Result