Pack-Years of Smoking
Transcription
Pack-Years of Smoking
Pack-Years of Smoking www.practicingclinicians.com • To calculate smoking pack-years: – Divide the number of cigarettes smoked per day by 20 (the number of cigarettes in a pack) – Then multiply by the number of years smoked (70 cigarettes/day ÷ 20 cigarettes/pack) X 10 years = 35 pack-years (35 cigarettes/day ÷ 20 cigarettes/pack) X 20 years = 35 pack-years (20 cigarettes/day ÷ 20 cigarettes/pack) X 35 years = 35 pack-years 1 Smoking Exposure and Decline in Lung Function www.practicingclinicians.com FEV1 (% of predicted) 85 80 Sustained Quitters 75 Intermittent Quitters 70 Continuous Smokers 65 60 0 1 2 3 4 5 6 7 Year 2 Anthonisen NR, et al. Am J Respir Crit Care Med. 2002;166(5):675-679. 8 9 10 11 Characteristics That Help Distinguish COPD From Asthma www.practicingclinicians.com Feature Onset Family history Medical or social history Patients report symptoms as... Airflow obstruction 3 COPD Asthma Often in midlife Often in childhood Variable Often Smoking (often ≥20 pack-years) Atopy (ie, allergy and/or eczema) Most notable during exercise Most notable at night or early morning “Mostly bad days” “Mostly good days” May be some reversibility with bronchodilation Largely reversible with bronchodilation Briggs DD Jr, et al. J Respir Dis. 2000;21(9A):S1-S21. Doherty DE. Am J Med. 2004;117(12A):11S-23S. Clinicians Fail to Distinguish COPD From Other Respiratory Diseases www.practicingclinicians.com Episodic Variable Asthma Allergy Rhinitis Eczema (atopy) Cough Dyspnea Chest Tightness Wheezing Heavy sputum production COPD Shared Symptoms 4 Chronic Progressive Key Indicators of COPD www.practicingclinicians.com • Chronic cough – Present intermittently or every day – Often present throughout the day; seldom only nocturnal • Chronic sputum production – Any pattern chronic sputum production may indicate COPD • Dyspnea that is: – Progressive (worsens over time) – Persistent (present every day) – Worse with exercise – Worse during respiratory infections 5 “Normal” Test Results in the Early Stages of COPD www.practicingclinicians.com Changes Can Be Seen Earlier in Spirometry Than in Many Other Respiratory Parameters Spirometry Symptoms Arterial blood gas Chest X-ray Normal Borderline Mild Cough, sputum Normal Normal Time 6 Moderate Exertional dyspnea Severe Resting dyspnea Hypoxemia Hyperinflation Volume-Time Curve Normal www.practicingclinicians.com FVC Exhaled Volume (L) 5 4 FEV1 3 2 1 1 2 3 4 Time (seconds) 7 FVC = forced vital capacity. 5 6 Robert’s Attempted Tracing 1 (Cough and Early Stop) www.practicingclinicians.com Exhaled Volume (L) 5 4 3 2 1 1 2 3 4 Time (seconds) 8 5 6 GOLD Diagnosis and Staging of COPD: Postbronchodilator Spirometry Values www.practicingclinicians.com Postbronchodilator Values FEV1/FVC FEV1 (postbronchodilator % of predicted) I: Mild <.70 ≥80% II: Moderate <.70 ≥50%, <80% III: Severe <.70 ≥30%, <50% IV: Very severe <.70 <30%a GOLD Stage aOr 9 <50% plus chronic respiratory failure. GOLD Executive Committee. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Gold web site. http://www.goldcopd.org. Updated 2008. Bronchodilator Reversibility Testing Helps Differentiate COPD From Asthma www.practicingclinicians.com Acceptable spirogram Yes Obstructive defect Is FVC low? Yes Is FVC low? Yes No Is FEV1/FVC ratio low? Restrictive defect No Pure obstruction Mixed obstructive/ restrictive defect or hyperinflation Further testing 10 Near-total reversal with use of β-agonist? Yes No Asthma COPD Further testing Petty TL. Spirometry made simple. National Lung Health Education Program web site. http://www.nlhep.org/resources/SpirometryMadeSimple.htm. Published January 1999. No Normal Robert’s Spirometry Results www.practicingclinicians.com Exhaled Volume (L) 5 Normal 4 FV C 3 FEV1 2 1 Measure FEV1 Predicted % Predicted 2.1 L 3.4 L 61% FVC 3.2 L FEV1/FVC 1 2 3 4 Time (seconds) 11 5 6 Value .65 Spirometry-Based Diagnosis Dictates How to Implement Evidence-Based Therapy www.practicingclinicians.com GOLD Stage I Mild II Moderate III Severe IV Very Severe Active reduction of risk factors: influenza vaccine. Add short-acting bronchodilators when needed Add regular Rx with 1 long-acting bronchodilator. Add rehabilitation Add inhaled corticosteroids if repeated exacerbations Long-acting bronchodilators and corticosteroids are also used for asthma but in the reverse order. GOLD Executive Committee. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Gold web site. 12 http://www.goldcopd.org. Updated 2008. Consider O2 and surgery Questionnaire to Differentiate Asthma and COPD www.practicingclinicians.com Questionnaire Score • Symptoms compiled Patients (%) 40 30 20 10 0 <3 3-5 6-8 COPD 13 Beeh KM, et al. Respir Med. 2004;98(7):591-597. 9-11 Asthma ≥12 from chart review to create quantitative questionnaire • Scores based on • Age of symptom onset • Smoking history • Atopy status • Cough quality • High scores associated with COPD, lower with asthma Donna’s Spirometry Results www.practicingclinicians.com Exhaled Volume (L) 5 Normal 4 FV C 3 FEV1 2 1 Measure FEV1 Predicted % Predicted 2.0 L 3.7 L 54% FVC 3.4 L FEV1/FVC 1 2 3 4 Time (seconds) 14 5 6 Value .58 All Smoking Cessation Pharmacotherapies Have Significant Benefit www.practicingclinicians.com Pharmacotherapy Odds Ratio (95% CI) Bupropion 2.12 (1.76-2.56) Nicotine gum 1.65 (1.37-2.01) Nicotine inhaler 2.18 (1.38-3.45) Nicotine nasal spray 2.37 (1.57-3.60) Nicotine patch 1.88 (1.60-2.22) Nicotine tablet 2.06 (1.47-2.87) Varenicline 2.55 (1.99-3.24) Favors placebo Favors treatment 0.2 1.0 7.0 Odds Ratio (95% CI) Cl = confidence interval. 15 Eisenberg MJ, et al. CMAJ. 2008;179(2):135-144. Explaining “Lung Age” to Patients www.practicingclinicians.com Susceptible smoker Never smoked or not susceptible to smoke Disability Death Lung Function FEV1 (% of value at age 25) 100 75 50 Age 52 with equivalent FEV1 of a 75-year-old 25 0 25 50 Age (years) 16 Parkes G, et al. BMJ. 2008;336(7644):598-600. 75