UPDATES ON COPD AND HYPERTENSION
From the 39th Annual Review Course for the Family Physician, presented February 27 to March 3, 2006, by the
University of Tennessee Health Science Center, College of Medicine, Memphis
| COPD UPDATE —Raymond R. Walker, MD, Associate Professor, Department of Family Medicine, University of Tennessee
Health Science Center, College of Medicine, Memphis
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| Evaluation for chronic obstructive pulmonary disease (COPD): perform complete patient history and physical
examination; look for comorbidities and signs of pulmonary disease (eg, hyperexpanded or hyperresonant chest); differentiate
between chronic bronchitic patients and emphysematous patients
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| Chronic bronchitic patients: present with chronic productive cough; audible wheezing; dyspnea on exertion; symptom-free
periods; patients may be cyanotic and develop pulmonary hypertension; can become hypoxic or hypercapnic
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| Emphysematous patients: present with labored breathing with exertion; complain of dyspnea at rest and shortness of
breath; difficulty breathing at rest; fatigue; no exercise tolerance; patients become anxious; weight loss as disease
progresses; occasional cough with sputum production; distant or decreased air sounds from air trapping; patients tachypneic
with fast pursed-lip breathing; increased chest cavity; patients usually not cyanotic and may develop hypotension;
arterial blood gases (ABGs) may be near normal early on
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| Treatment: inhaled steroids; patients with acute exacerbations may require oral or injected steroids; if disease becomes
severe, patients may require long-term oral prednisone therapy; obtain bone density study; consider sleep apnea study for
obese patients and consider continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP); if
patient on theophylline, check theophylline level
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| Chest x-ray: confirms diagnosis; rules out acute problems (eg, pneumonia); emphysematous patients—shows occult
lung malignancies in patients with strong history of tobacco use; hyperexpanded or overinflated lungs and small heart;
chronic bronchitic patients—lungs normal; may have enlarged heart; repeat chest x-ray annually to monitor progression
of disease
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| Spirometry or pulmonary function tests (PFTs): usual forced expiratory volume in 1 sec (FEV1 ) ≥80% of predicted
value; usual vital capacity 3 to 5 L; FEV1 increases ≈12% (≈200 mL) in response to bronchodilator
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| Diagnosis of COPD: mild—decreased FEV1 (50%-70% of predicted value); bronchodilators increase FEV1 ;
moderate—FEV1 35% to 49% of predicted value; minimal to no response to bronchodilators; consider home O2 therapy;
severe—FEV1 <35% of predicted value; patients have chronic symptoms and do not respond to bronchodilators;
patients can develop sleep apnea; check ABGs for alkalosis; evaluate thyroid function for associated hypothyroidism
from emphysematous symptoms
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| Pulse oximetry: saturation ≈95% normal; home O2 therapy should result in saturation of 90% to 95%; perform baseline
study to monitor for deterioration; patients with significant changes from baseline may need home O2 therapy
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| ABGs for stages of emphysema or COPD: stage A —PaO 2 80 to 100 mm Hg; stage B—PaO 2 60 to 80 mm Hg;
PaCO 2 increases to >45 mm Hg; patients respond well to home O2 therapy; as hypoxia increases with progression of disease,
overoxygenation can decrease respiratory drive and result in need for ventilation (difficult to wean patients); stage
C—PaO 2 drops below 60 mm Hg; PaCO 2 decreases eventually; modified O2 therapy (may be as low as 1-2 L)
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| Sputum Gram’s stain and culture and sensitivity (C/S): important if patient presents with COPD flare; helps determine
which antibiotics to use (adjust for resistance for local problems); rules out comorbid conditions (eg, tuberculosis
[TB], Legionella infection, fungal infection, Pneumocystis jiroveci pneumonia)
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| Electrocardiography (ECG): rule out primary coronary artery disease (CAD); look for right-sided heart failure; as disease
progresses, patients may develop dysrhythmias; β-agonists (inhaled bronchodilators or theophylline) can result in tachycardia
and cardiac arrhythmia; patients who fail 6-min stress test (ie, unable to walk 200 m in 6 min) benefit from home
O2 therapy (document for reimbursement from insurance company)
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| Bone density evaluation: older patients at risk for osteoporosis; as disease worsens and patients started on inhaled corticosteroids,
long-term prednisone therapy, or repeated courses of short-term prednisone therapy, risk for osteoporosis and bone
loss increases significantly; perform baseline dual-energy x-ray absorptiometry (DEXA) scanning and repeat every 2 yr; be
prepared to put patients on medications and calcium supplementation
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| Sleep apnea: obstructive—usually in obese patients; central—usually in patients with hyperexpanded chest and lungs
with air trapping; evaluate patients who complain of nocturnal dyspnea; talk to spouse about sleep problems
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| Theophylline: can improve respiratory drive, especially in patients with sleep apnea; check levels periodically to avoid
toxicity (>20 µg/mL; goal 8-12 µg/mL)
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| Treatment: bronchodilators initial treatment; ipratropium (Atrovent) preferred due to better response than with β2 -agonists;
β2 -agonists helpful for acute flare; as disease becomes moderate to severe, consider adding theophylline as baseline
long-term bronchodilator (decreases use of β2 -agonists); expectorants or mucolytics—consider for coughing
problems with occasional sputum production or chronic bronchitis; acetylcysteine; organic iodide; guaifenesin useful
(long-acting pill taken twice daily; shorter-acting pill taken qid); 15 to 30 mL of dextromethorphan (Robitussin) every 4
to 6 hr; make sure patients well hydrated; aerosol therapy—spacers useful for patients with difficulty using aerosols;
newer delivery methods better tolerated; fluticasone and salmeterol (Serevent) combination (Advair Diskus) available in
powdered form (patients do not have to coordinate pushing metered dose inhaler [MDI] with inhaling); tiotropium
(Spiriva) long-acting bronchodilator available in powdered form; β-agonists—albuterol (Proventil, Ventolin) fairly
effective especially in mild disease; as disease progresses, anticholinergic medications become mainstay of treatment,
provide more extended relief, and help reduce β-agonist use; combination of ipratropium and albuterol (Combivent)
taken 3 to 4 times daily fairly effective; (patients require β-agonist MDI for breakthrough problems; more aggressive
treatment required if used frequently); for acute exacerbations or pneumonias, appropriate antibiotic therapy useful; consider
amantadine as antiviral agent; pneumococcal vaccine and yearly influenza vaccine; steroids useful for acute flares;
as disease becomes more severe, inhaled steroids may become more useful; oral prednisone for acute flare (taper over 10-
14 days); inhaled steroids—triamcinolone (Azmacort), flunisolide (AeroBid), and fluticasone (Flovent; available in
powdered form) work fairly well with adequate dosing and appropriate time intervals; consider costs; acute exacerbation
of COPD and hospitalization—start with intravenous (IV) methylprednisolone qid and convert to oral prednisone
over 1 to 2 days (continue for at least 1.5-2.0 wk); in patients who require hospitalization or who are deteriorating,
follow-up spirometry 2 wk after flare helpful for monitoring changes from baseline
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 | Other interventions: tobacco smoking cessation; nicotine replacement (eg, bupropion [Zyban, Wellbutrin]); pulmonary rehabilitation
and/or physical therapy; supplemental O2 therapy—maintain PaO 2 ≥60 mm Hg or O2 saturation >90%; in severe
disease, mortality decreased with low-flow (≈2 L) continuous O2 therapy; consider CPAP or BiPAP for continued problems
or sleep apnea; as disease progresses, consider long-term O2 therapy; if PaO 2 drops to 50 to 59 mm Hg, O2 saturation drops
to ≈88%, or if patient has hematocrit >55%, congestive heart failure (CHF), or cor pulmonale, long-term O2 therapy at low
flow rate beneficial; intubation in acute flare last resort; pulmonary rehabilitation, physical therapy, and patient education
manage symptoms, improve quality of life, improve breathing, and develop exercise tolerance; aerobic exercise for 45 min 2
to 3 times weekly for 6 wk to improve strength; isometric exercises; surgery—last resort; in nonsmoking patients, lung
transplantation possibility; patients with severe bullous disease may benefit from lung reduction surgery; indications for
lung reduction surgery—severe emphysematous changes with CT evidence of bilateral upper lobe involvement; no tobacco
use for ≥6 mo; no history of CHF, ejection fraction <45%, or pulmonary hypertension; ability to walk ≥140 m in 6
min; patients with pulmonary hypertension and right-sided heart failure need heart and lung transplantation
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| HYPERTENSION UPDATE —Ira Keith Ellis, MD, Clinical Instructor, Department of Family Medicine Residency Program,
University of Tennessee Health Science Center, Jackson
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| Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 7): presented in 2003; in patients >50 yr of age, systolic blood pressure (BP)
considered more important than diastolic BP; isolated systolic hypertension in elderly still problematic; if BP of 115/75
mm Hg considered baseline for normal individuals, risk for stroke doubles with every 20-mm Hg increment above baseline
systolic BP or 10-mm Hg increment above diastolic BP; chance of developing clinical hypertension at age ≥55 yr
90%; prehypertension (systolic BP 120-139 mm Hg; diastolic BP 80-89 mm Hg) warning sign of need for lifestyle modification
and antihypertensive therapy
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| Therapy recommendations: thiazide diuretics as initial monotherapy; if patient has comorbidities (eg, diabetes), consider
other medications with secondary benefits; 2 agents recommended for patients with systolic BP ≥20 mm Hg or diastolic
BP ≥10 mm Hg above goal; JNC 7 recommends “you use your own judgment above theirs” (eg, if patient does not
fit clearly into category, altering therapy and goal for individual’s benefit acceptable); overly aggressive BP therapy may
cause harm (eg, orthostasis and falls) to elderly patients
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| Classification and goals: stage II—160/100 mm Hg; stage I—systolic BP 140 to 159 mm Hg systolic, diastolic BP 90 to
99 mm Hg; normal or optimal—≤120/80 mm Hg; prehypertension—systolic BP 120 to 139 mm Hg, diastolic BP 80 to 89
mm Hg; goals—in patients with no comorbidities, ≤140/90 mm Hg; in patients with diabetes or chronic kidney disease, 130/
80 mm Hg
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| Techniques for BP measurement: in-office—2 readings 5 min apart; patient should be seated and have refrained
from caffeine intake or strenuous activity; ambulatory monitoring and self-BP measurement—controversial; ask patients
to bring home measuring device to physician visit and compare to in-office readings; if BP reading inconsistent
with patient’s history, repeat measurement
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| Management of patients with hypertension: evaluate lifestyle and cardiovascular risk factors; check for pheochromocytoma;
assess for target end organ damage; risk factors—tobacco smoking; obesity; physical inactivity; high cholesterol;
diabetes; glomerular filtration rate (GFR) <60 mL/min; advanced age; family history of premature coronary disease;
causes—pheochromocytoma; sleep apnea; drugs (eg, naproxen [Aleve], cocaine); alcohol use; aspirin and sulindac (Clinoril)
shown not to elevate BP or negate beneficial effects of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-
receptor blockers (ARBs); kidney disease; renal vascular disease; steroid therapy; Cushing’s syndrome; coarctation of aorta;
parathyroid disease
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| Target end organ damage: laboratory studies include complete blood count (CBC) to check for anemia, Chem 7 or
basic metabolic panel (BMP) to check for renal disease, ECG to check for enlarged heart; consider performing chest x-
ray, urinalysis, and screening for microalbuminuria; consider cerebral edema in patients with elevated BP and headache;
glucose; potassium; creatinine; check lipid profile to assess risk for myocardial infarction (MI) or stroke; urinary albumin
testing optional; if BP controlled by lifestyle modification or normal therapy (ie, ≤3 agents at maximum dosage), further
evaluation not required; other studies (eg, urinary metanephrine) not recommended unless patient has resistant hypertension,
known hypertension suddenly difficult to control, or severe hypertension in younger patients
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| Other treatment modalities: exercise; reduce alcohol and sodium intake; Dietary Approaches to Stop Hypertension
(DASH) diet; BP decreases by 20 mm Hg for every 20-lb reduction in body weight
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| Selecting agents: stage I hypertension with no significant comorbidities—thiazide diuretics; ACE inhibitors;
ARBs; β-blockers; calcium channel blockers; any combination can be used; stage II hypertension—2-drug combination
including thiazide-type diuretic; reduce BP to goal; heart failure—thiazides, β-blockers, ACE inhibitors, ARBs, and aldosterone
antagonists (eg, spironolactone) shown to improve morbidity and mortality, regardless of effect on BP reduction;
MI— β-blockers, ACE inhibitors, and aldosterone antagonists shown to reduce repeat MI and subsequent events, regardless
of effect on BP reduction; high risk —thiazides; β-blockers; ACE inhibitors; calcium channel blockers; improvement in
mortality and morbidity with ARBs similar to that of ACE inhibitors in most conditions, but ARBs 2 to 3 times more expensive;
chronic kidney disease—ACE inhibitors; ARBs; recurrent stroke—thiazides and ACE inhibitors; black patients respond
differently to ACE inhibitors, ARBs, and β-blockers, but response to diuretics and calcium channel blockers equivalent
to white patients; large left ventricle—can be resolved with adequate BP treatment; if patient needs vasodilators (eg, hydralazine,
minoxidil), anticipate left ventricle enlargement; peripheral artery disease—exercise improves claudication;
carries same risk as in diabetes
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| Older patients: treat isolated systolic hypertension; start agents with low dose and increase slowly; assessing BP—
repeat BP measurement in standing patient (standing BP acceptable 75% of time); be careful about overaggressive therapy
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| Other points: controlling BP can decrease rates of dementia; women and oral contraceptives (OCs)—ask women to
refrain from taking OCs for 2 to 3 days; BP often elevated in response to estrogen; consider changing to nonestrogen
form of birth control; hypertension in children—defined as 95th percentile based on age; consider lifestyle modification
(eg, physical activity for 1 hr daily) in adolescents ≤18 yr of age and weight maintenance; hospitalization—eg, asymptomatic
man presents with BP 210/110 mm Hg; limited blood work shows no acute change in renal function or ECG;
no acute onset of hematuria or proteinuria; patient can go home with standardized BP regimen; follow up in 2 days
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Educational Objectives
| The goal of this program is to educate the listener about the diagnosis and management of chronic obstructive pulmonary
disease (COPD) and hypertension. After hearing and assimilating this program, the participant will be better able to:
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| 1. Distinguish chronic bronchitic patients from emphysematous patients.
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| 2. Diagnose and classify severity of COPD, based on clinical findings.
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| 3. Select appropriate therapy for patients with COPD.
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| 4. Review guidelines and recommendations for treatment of hypertension.
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| 5. Counsel patients about pharmacologic therapy and lifestyle modification for treatment of hypertension.
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Discussed on This Program
Acetylcysteine (N -acetylcysteine) [Acetadote, Mucomyst, Mucosil-10, -20]
Albuterol (salbutamol sulphate in United Kingdom) [AccuNeb, Proventil, Proventil HFA, Proventil Repetabs, Ventolin,
Ventolin HFA, Volmax]
Bupropion HCl [Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban]
Dextromethorphan HBr (several trade names)
Flunisolide [AeroBid, AeroBid-M, AeroSpan, Nasarel]
Fluticasone propionate [Cutivate, Flovent, Flovent HFA, Flovent Diskus, Flovent Rotadisk, Flonase]
Fluticasone propionate/salmeterol [Advair Diskus]
Guaifenesin (glyceryl guaiacolate) (several trade names)
Hydralazine HCl [Apresoline]
Influenza virus vaccine [Fluarix, FluMist, Fluvirin, Fluzone]
Ipratropium bromide [Atrovent]
Ipratropium bromide and albuterol sulfate [Combivent, DuoNeb]
Minoxidil [Loniten, Minoxidil for Men, Rogaine]
Naproxen [Aleve, Anaprox, Anaprox DS, EC-Naprosyn, Naprosyn, Naprelan]
Pneumococcal 7-valent conjugate vaccine (diphtheria CRM197 protein) [Prevnar]
Pneumococcal vaccine, polyvalent [Pneumovax 23]
Prednisone (several trade names)
Salmeterol xinafoate [Serevent Diskus]
Spironolactone [Aldactone]
Sulindac [Clinoril]
Theophylline (several trade names)
Tiotropium bromide [Spiriva]
Triamcinolone (oral) [Aristocort, Atolone, Kenacort]
Suggested Reading
Adams R et al: Exacerbations of chronic obstructive pulmonary disease--a patients' perspective. Prim Care Respir J
15:102, 2006; Bellamy D et al: International Primary Care Respiratory Group (IPCRG) Guidelines: management of
chronic obstructive pulmonary disease (COPD). Prim Care Respir J 15:48, 2006; Brown DJ et al: Prevalence of hypertension
in a sample of Black American adults using JNC 7 classifications. J Natl Black Nurses Assoc 16:1, 2005; Chen K
et al: Patient satisfaction with antihypertensive therapy. J Hum Hypertens 19:793, 2005; Cuddy ML: Treatment of hypertension:
guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure 1). J Pract Nurs 55:17, 2005; Haughney J et al: Patient-centred outcomes
in primary care management of COPD - what do recent clinical trial data tell us? Prim Care Respir J 13:185, 2004; Holcomb
SS: Selection of antihypertensive agents in patients at risk for diabetes. Curr Hypertens Rep 7:461, 2005; Liszka
HA et al: Prehypertension and cardiovascular morbidity. Ann Fam Med 3:294, 2005; Neutel JM et al: Efficacy of
combination therapy for systolic blood pressure in patients with severe systolic hypertension: the Systolic Evaluation of
Lotrel Efficacy and Comparative Therapies (SELECT) study. J Clin Hypertens (Greenwich) 7:641, 2005; Qureshi AI
et al: Prevalence and trends of prehypertension and hypertension in United States: National Health and Nutrition Examination
Surveys 1976 to 2000. Med Sci Monit 11:CR403, 2005; Staffileno BA: Treating hypertension with cardioprotective
therapies: the role of ACE inhibitors, ARBs, and beta-blockers. J Cardiovasc Nurs 20:354, 2005; Steuten LM et al:
COPD as a multicomponent disease: inventory of dyspnoea, underweight, obesity and fat free mass depletion in primary
care. Prim Care Respir J 15:84, 2006; Thomas M et al: COPD management in the community: early detection and proactive
care. Prim Care Respir J 14:5, 2005; White P: Response to: The necessity for spirometry in the primary care management
of COPD. Prim Care Respir J 13:15, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Walker and Ellis were recorded in Memphis, TN, at the 39th Annual Review Course for the Family Physician,
presented February 27 to March 3, 2006, by the University of Tennessee Health Science Center, College of Medicine.
The Audio-Digest Foundation thanks the speakers and the University of Tennessee for their cooperation in the production
of this program.
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