Know the Warning Signs of COPD

Katarzyna LaLicata, MSN, FNP-C, FNP-BC
Thursday February 14, 2019
In the beginning stages of chronic obstructive pulmonary disease (COPD), patients may have no symptoms or mild ones. However, as the disease progresses, symptoms may include chest tightness, a cough with mucus production, a low fever, shortness of breath, and wheezing.1 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) no longer emphasizes distinguishing chronic bronchitis from emphysema, the 2 main types of COPD. It instead focuses on the airflow-limited state.2

COPD is a disease whose hallmark features include persistent respiratory symptoms accompanied by airflow limitation that is secondary to airway and/or alveolar abnormalities, often caused by significant exposure to noxious gases or particles.3

Chronic bronchitis is defined as the presence of cough and sputum production for at least 3 months a year in each of 2 consecutive years, according to GOLD’s 2019 report.3

Histologically, chronic bronchitis is characterized by mucous gland hyperplasia, with a relatively undamaged pulmonary capillary bed, unlike emphysema.4 Pathologically, emphysema is characterized by abnormal enlargement of air spaces distal to the terminal bronchiole, with permanent destruction of their walls without obvious fibrosis.5

Patients with chronic bronchitis and emphysema may be differentiated by their presentation, including associated cardiac findings, lung assessment findings, sitting position in the office, type of cough, and weight. Those with chronic bronchitis may be obese and experience frequent coughing with expectorant, coarse rhonchi and wheezing on lung exam, and edema and cyanosis that can be associated with right-sided heart failure. They also may be thin and have barrel chests. Hyper-resonant lung sounds and wheezing may be heard, or they may have pursed lip-breathing accompanied by a tripod position and use of accessory muscles and little or no cough or expectorant reported.4 On chest radiography, findings include increased broncho vascular markings and cardiomegaly. Emphysema shows increased anteroposterior diameters and retrosternal airspace, flattened diaphragms, and hyperinflation.6

COPD diagnosis is made with spirometry, when the ratio of forced expiratory volume in 1 second is less than 70% of a match control, signifies an obstructive defect. A high-resolution computed tomography can help diagnose emphysema, given that it has better sensitivity then a chest radiograph.

The 6 minute walk test is part of the BODE index to predict mortality for patients with COPD. Other tests used for the work-up of COPD to aid in diagnosis or determine worsening progression include alpha-1 antitrypsin, arterial blood gases, b-type natriuretic peptide and N-terminal pro b-type natriuretic peptide, electrocardiography, serum chemistries and hematocrit, right-sided heart catheterization, sputum evaluation, and 2 dimensional echocardiogram.4 Differential diagnosis of COPD can include asthma, bronchiectasis, congestive heart failure, diffuse pan bronchiolitis, and obliterative borchiolitis.3

The key to managing COPD is a thorough assessment that includes spirometry testing, the nature and magnitude of the symptoms, history of moderate and severe exacerbations and future risk, and presence of comorbidities, such as diabetes, gastroesophageal reflux disease, heart failure, and osteoporosis. The GOLD (2019) refined ABCD assessment tool can be used to guide treatment.3 Treatment goals include improving exercise tolerance and health status, preventing disease progression, preventing and treating exacerbations, reducing mortality, and relieving symptoms. Smoking cessation is key to managing chronic bronchitis and COPD.3

COPD exacerbation can be managed in the outpatient setting, but it is important to determine if it is life-threatening and indicates hospitalization.3 Treatment includes medications, such as inhaled or oral corticosteroids, short- and long-acting β2-agonist bronchodilators, phosphodiesterase 3 inhibitors, respiratory anticholinergics, and a combination medication of β2 agonists and corticosteroids or anticholinergic inhalations. Treatment may also include an improved diet, infection control, management of sputum viscosity and clearance, oxygen therapy, pulmonary rehab, smoking cessation, vaccinations, and alpha-1 antitrypsin deficiency treatment to aid the patient’s functional status and quality of life.4 Short-term use of codeine or dextromethorphan can also help with management of a cough associated with chronic bronchitis.7

Chronic bronchitis is the beginning point of the progression of COPD. As of 2017, research was focusing on the actual mucus itself, especially the concentration of mucin, which is abnormally high in patients with chronic bronchitis. The University of North Carolina School of Medicine in Chapel Hill is working to analyze mucin concentration and phlegm samples.8 Pulmonologists at the University of Iowa Hospital & Clinics in Iowa City also are working on clinical trials for patients with chronic bronchitis by attempting to kill cells that produce mucus with low-level energy.9

The FDA recently approved the first and only digital inhaler with a built-in sensor that can monitor the usage and strength of a user’s inhalation. The ProAir Digihaler is approved for patients 4 years and older and will be available in 2019, with a national launch in 2020.10 Clinical studies are also under way for the angiotensin II receptor blocker losartan in the management of chronic bronchitis and COPD.11 Families can also test for alpha-1 deficiency if there is a family history of COPD or liver disease.12

CONCLUSION
Chronic bronchitis and emphysema are progressive lung diseases under the umbrella term of COPD. Improving care for patients is important to help prevent and treat COPD exacerbations and prevent COPD-related admissions and readmissions. The GOLD (2019) report can aid providers in determining the best individualized treatment plans. To allow for a quick diagnosis and early intervention, counsel patients to alert their providers if they have a cough lasting at least 3 months a year for 2 consecutive years. ®


Katarzyna LaLicata, MSN, FNP-C, FNP-BC, is a nurse practitioner at CVS Minute Clinic and an associate clinical assistant professor at National University in San Diego, California.


REFERENCES
  1. US National Library of Medicine. Chronic bronchitis. MedlinePlus website. medlineplus.gov/chronicbronchitis.html. Accessed December 28, 2018.
  2. Boka K, Ouellette DR. Emphysema. Medscape website. emedicine.medscape.com/ article/298283-print. Updated August 21, 2016. Accessed December 28, 2018.
  3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report. GOLD COPD website. goldcopd.org/wp-content/uploads/2018/11/ GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. Accessed December 28, 2018
  4. Mosenifar Z, Harrington A, Nikhanj NS, Kamangar N. Chronic obstructive pulmonary disease (COPD). Medscape website. emedicine.medscape.com/article/297664-print. Updated November 15, 2018. Accessed December 28, 2018
  5. Chestnutt MS, Prendergast TJ, Tavan ET. Pulmonary disorders. In: Papadakis MA, McPhee SJ, Rabow SW, eds. Current Medical Diagnosis & Treatment. 53rd ed. New York, NY: McGraw Hill; 2014:250-251.
  6. Kleinschmidt P. Chronic obstructive pulmonary disease (COPD) and emphysema in emergency medicine. Medscape website. emedicine.medscape.com/article/807143-print. Updated and published October 25, 2018. Accessed January 16, 2019.
  7. Clinical Resource, Treatment of Cough in Adults. Pharmacist’s Letter/Prescriber’s Letter. January 2018. prescriber.therapeuticresearch.com/Content/Segments/ PRL/2015/Feb/Treatment-of-Cough-in-Adults-8095.
  8. University of North Carolina Health Care. Chronic bronchitis: new insights could lead to first diagnostic test, better treatments. ScienceDaily website. sciencedaily. com/releases/2017/09/170906221217.htm. Published September 6, 2017. Accessed December 28, 2018
  9. McCarver KA. UIHC seeks a cure for chronic bronchitis. The Daily Iowan. November 29, 2018. dailyiowan.com/2018/11/29/uihc-seeks-a-cure-for-chronic-bronchitis. Accessed December 28, 2018
  10. Brooks M. FDA approves first digital inhaler with tracking app. Medscape website. medscape.com/viewarticle/906940_print. Published December 24, 2018. Accessed December 28, 2018.
  11. Effect of Losartan on Airway Mucociliary Dysfunction in Patients With COPD and Chronic Bronchitis. clinicaltrials.gov/ct2/show/NCT02416102. Updated February 7, 2018. Accessed December 28, 2018
  12. Howley EK. Does COPD have a genetic component? US News and World Report. June 2, 2017. health.usnews.com/health-care/patient-advice/articles/2017-06-02/doescopd-have-a-genetic-component. Accessed December 28, 2018.


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