PANDEMIC PREPARATION/COPD
From the 50th Annual Scientific Assembly of the American Academy of Family Physicians, October 3-6, 2007, Chicago, IL
| PREPARING FOR INFECTIOUS DISEASE PANDEMIC s —Charles W. Mackett III, MD, Associate Professor and
Executive Vice Chair, Department of Family Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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| Subtypes of avian influenza A viruses: H5—H5N1 strain spread across Asia and into Europe and Africa due to
trafficking of poultry and migration of wild birds; continues to evolve; potential to cause epidemic; H7—low pathogenicity;
found in Canada, resulting in ban of Canadian poultry by several nations; found in Italy; other influenza
outbreaks, with some infection in humans and whales; H9—cause of death in humans in 1990s in Netherlands;
H2—cause of Asian influenza pandemic of 1958; constituents of current seasonal influenza vaccine include H3N2
(variant of virus seen in influenza pandemic of 1968) and H1N1 (variant seen in great pandemic of 1918); no longer
immunize against H2 (patients born before 1958 may be immune)
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| Current news about H5: continues to spread, reemerge, and mutate; crossed from poultry and wild birds into mammals
(eg, cats, dogs); as of October 2007, 329 confirmed human cases and 201 deaths (case fatality rate, 61%); Indonesia
country most affected by H5N1 (case fatality rate, 75%); no sustained transmission from human to human, but
virus continues to mutate; compared to 2006, number of human infections in 2007 decreased due to efforts to avoid
sick and dying poultry and limiting exposure to feces, secretion, and feathers of poultry; case fatality rate high; almost
all infected persons have respiratory distress syndrome and cytokine storm; inflammatory response “as dangerous as
virus itself”
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| Pandemic influenza: occurs 2 to 3 times per century; last pandemic 1968; what to expect from category 4 or 5 pandemic
in United States—25% of population affected in first wave, with assumed case fatality rate of 2.5%; 100 to
200 times volume of patients in local emergency department (ED); up to 2 million deaths (500,000-750,000 children);
demand would far exceed capacity; absence of up to 40% of health care workers; critical shortage of supplies,
equipment, and medications (eg, oseltamivir, zanamivir); United States plans to buy 40 million doses of
medication to cover 20 million high-priority patients (eg, military and government personnel, health care workers);
shift from standard community level of care to “sufficient” level of care; acute care (ie, deferring elective procedures);
needs of vulnerable populations
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| Resources for preparation: begin planning now; review Centers for Disease Control and Prevention (CDC) resources,
guidelines, and checklists and tailor to own practice; review checklist for preparing physician offices and
for business planning; master management of seasonal influenza; www.cdc.gov; www.aafp.org; www.pandemicflu.gov;
contact local or state public health officials (coordinate and review plans)
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| Management of pandemic influenza: symptoms—fever; sore throat; cough; dyspnea; acute onset; gastrointestinal
symptoms with signs of encephalitis or obtundation; history of travel to risky areas or exposure to sick or dying
poultry (including feathers, secretions, and feces); monitor media; designate single point of contact to receive public
health alerts and back-up person; keep high index of suspicion; report cases to public health department; primary
goals detecting, treating, and stopping spread of infection; make sure staff knows how to triage and isolate
cohort of patients who may be infected; proper cough etiquette; good hand hygiene most effective for preventing
spread; provide influenza bags containing mask, tissue, and alcohol-based hand sanitizer; appropriate personal protective
equipment (PPE) and masks for staff; droplet precautions; aerosol precautions for varicella and measles and
while performing invasive respiratory procedures; if performing cardiopulmonary resuscitation on patient with
acute respiratory illness, use fit-tested N95 or N100 mask; wash hands before and after every encounter; appropriate
immunization and treatment; master management of seasonal influenza, other respiratory illnesses, and community-acquired
pneumonia
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| Controlling patient flow in office: cohort patients (separate by ≥3 ft); have adequate waste disposal; use hand
sanitizers; language-appropriate signs so patients can alert health care provider when they have respiratory infections;
availability of influenza bags (containing, eg, tissues) for patients; appropriate PPE; demonstrations of proper
cough etiquette (cough into tissues or elbow, not into hands)
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| Immunizations: for patients >50 yr of age, patients <50 yr of age with risk factors, and children up to 5 yr of age;
every health care worker should be immunized unless contraindicated
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| Preparing for pandemic: coordinate with public health officials for help isolating, quarantining, and contacting
people and mandating social distancing; be ready to support and care for patients at home; be prepared for unavailability
of >40% of staff; deliver information about clinical epidemiology to decision-makers; do not forget vulnerable
populations (eg, patients with diabetes, heart failure, or HIV); understand plans of local specialty groups and
public health officials; talk to advocates of special populations; shift from long-term preventive care to acute care;
increase telephone triage; know local plans for alternative care sites for patients discharged from hospital or who
have minimal needs; know how state plans to distribute antiviral medications; be prepared to give care without
availability of vaccines; communicate at every level; make sure patients know which symptoms warrant alerting
health care provider; individual preparedness and self-care important; designate single practice spokesperson and
back-up person; business continuity critical; send guide to employees stating expectations on attending work; commit
to protect health care workers and their families; speaker’s facility keeps 10,000 to 12,000 courses of oseltamivir
on hand for employees; prepurchased PPE for up to 2 wk for every worker in direct clinical care; clear
guidelines and screening for returning to work after recovering from influenza (usually in 7-10 days; in pandemic
of 1918, patients had neurologic signs and symptoms for months); cross-train personnel; identify essential tasks required
to maintain office and make sure multiple people know how to do them; engage vendors and alternative suppliers
early; coordinate with payers, banks, and creditors; make sure able to meet payroll; anticipate significant
behavioral health needs of patients, family, staff, and palliative care centers; security to protect resources and facilities;
recovery and reconstitution; have plan to recall deferred patients after epidemic
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| COPD: TREATING THE WHOLE PERSON —Barbara P. Yawn, MD, MSc, Adjunct Professor, Department of
Family and Community Health, University of Minnesota Medical School, and Director of Research, Olmsted Medical
Center, Rochester, MN
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| Chronic obstructive pulmonary disease (COPD): airway flow limitation; preventable; treatable; not fully reversible;
usually progressive; inflammation—response to noxious particles (eg, tobacco smoke); neutrophilic rather
than eosinophilic (as seen in asthma); inhaled corticosteroids used as first-line therapy for asthma, but not for
COPD (response different in COPD)
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| Systemic consequences of COPD: emphysema—destruction of alveoli; hyperloosened areas seen on chest x-ray;
chronic bronchitis—more inflammation; hypersecretion and enlargement of mucus glands; chronic productive
cough; mortality in United States—high; increasing; greater increase in women due to increased tobacco smoking;
≈2 million people have severe lung disease; 10 million diagnosed with COPD (≈4 million treated); 4 to 10 million
with COPD not yet treated; musculoskeletal problems (eg, deconditioning, loss of muscle mass); depression (may
be inflammatory disease with physiologic connection to inflammation in lungs); cardiovascular disease
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| Pathogenesis of COPD: tobacco smoke affects patient with genetic susceptibility; alveolar macrophages and
CD8+ T lymphocytes produce enzymes (eg, proteases that break down alveoli); mast cells increase bronchoconstriction;
mucus hypersecretion; pathology—airway narrows; limited airflow in and out of lungs occurs due to
static and dynamic hyperinflation (patient unable to exhale and empty lungs completely with small breaths in)
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| Impact of COPD on functionality: muscle wasting; activity limitation; difficulty walking, lifting 10 lb, and performing
routine activities (starts long before expected due to effects of COPD outside of lungs); tobacco smoking
cessation—can change course of COPD; lung function in sustained quitters better than in patients who continue to
smoke; quitting intermittently can increase life expectancy
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| Evaluation: identify COPD before patients complain about shortness of breath (moderate to severe COPD); look at
forced expiratory volume in 1 sec (FEV1 ) and ask about changes in physical activity level in last 6 mo; be specific
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| Treatment: bronchoconstriction not reversible with β-agonists or anticholinergic agents; bronchodilators—first-
line therapy; effective for static and dynamic hyperinflation; do not cause significant improvement in FEV1 , but
can improve exercise capacity; low body weight—occurs in later stages of COPD; obese patients with COPD lose
muscle mass; counsel patients about nutrition (eg, increasing protein intake); investigational therapies include anabolic
steroids (may reverse muscle wasting) and addressing wasting of proteins; may be related to inflammatory
state (skeletal and muscular apoptosis may be reversed; recognize early because patients lose interest in eating, resulting
in further muscle wasting); deconditioning—shortness of breath with physical activity; patients unable to
socialize, resulting in further deconditioning; manage with pulmonary rehabilitation, nutrition education, and exercise;
pulmonary rehabilitation—one of most effective therapies for COPD; appropriate as soon as patients become
symptomatic with exercise; more effective than antidepressants alone for depression associated with COPD; poor
sleep quality—leads to further aggravation of depression and daytime sleepiness; consider bilevel positive airway
pressure (BiPAP); ask about sleep problems early to avoid further problems (eg, sleep apnea); combination of poor
sleep quality and COPD affects daytime physical activity; increased duration of hypoxia with sleep apnea increases
risk for cardiovascular disease, stroke, and hypertension; ask patients, “do you wake up feeling somewhat refreshed?”
and “are you sleepy all day?”; ask spouse or partner about sleep pattern and snoring
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| Case presentation: woman 61 yr of age with positive history of tobacco smoking; heard about COPD on radio;
smoker’s cough for 2 yr; 3 long episodes of bronchitis in last 2 yr; difficulty walking up stairs from basement while
carrying laundry; father died of emphysema at age 72 yr; FEV1 to forced vital capacity (FVC) ratio abnormal (FEV1
lower than predicted [50%-52%; woman has moderate to severe COPD]); signs of emphysema; lifestyle changes
(eg, intermittent tobacco smoking cessation) over last 4 yr; body mass index (BMI) 22 and stable; suspected gallop
rhythm; nonpitting pedal edema; chest x-ray ruled out lung cancer; consider bronchodilators and inhaled corticosteroids;
BODE index—helps assess total-body effect of COPD; evaluate BMI, airflow obstruction (FEV1 ), dyspnea,
and exercise tolerance (6-min walking distance); used for looking at prognosis and other issues associated with
COPD; what to discuss with patient—increased risk for lung cancer and benefits of smoking cessation; congestive
heart failure; coronary artery disease; screening for depression; sleep problems (talk to spouse, too); endocrine problems
(common; may affect management of COPD; consider effects of oral steroids on diabetes control); musculoskeletal
problems (high-dose inhaled corticosteroids can increase risk for osteoporosis and loss of muscle mass);
consider dual-energy x-ray absorptiometry (DEXA) and therapy for osteoporosis; colon cancer screening; Papanicolaou
testing; osteoporosis screening; immunizations—diphtheria and tetanus toxoids and acellular pertussis vaccine,
adsorbed (DTaP); yearly influenza vaccine; pneumococcal vaccine, polyvalent (Pneumovax 23); live zoster vaccine
(Zostavax)
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| Conclusion: lungs filter tobacco smoke, but numerous irritants and toxins enter bloodstream and systemic organs;
since COPD is reaction to toxins, consider effects on other organ systems
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Suggested Reading
Ambrosino N et al: New strategies to improv.exercise tolerance in chronic obstructive pulmonary disease. Eur
Respir J 24:313, 2004; Ciobanu L et al: Current opinion on the importance of pulmonary rehabilitation in patients
with chronic obstructive pulmonary disease. Chin Med J (Engl) 120:1539, 2007; Costes F et al: Noninvasive ventilation
during exercise training improves exercise tolerance in patients with chronic obstructive pulmonary disease. J Cardiopulm
Rehabil 23:307, 2003; Crowe J et al: Inspiratory muscle training compared with other rehabilitation
interventions in adults with chronic obstructive pulmonary disease: a systematic literature review and meta-analysis.
COPD 2:319, 2005; Ferrari M et al: Minimally supervised home rehabilitation improves exercise capacity and
health status in patients with COPD. Am J Phys Med Rehabil 83:337, 2004; Kamahara K et al: Circuit training for
elderly patients with chronic obstructive pulmonary disease: a preliminary study. Arch Gerontol Geriatr 39:103, 2004;
Ngaage DL et al: The functional impact of an individualized, graded, outpatient pulmonary rehabilitation in end-
stage chronic obstructive pulmonary disease. Heart Lung 33:381, 2004; Reardon J et al: Pulmonary rehabilitation
for COPD. Respir Med 99 Suppl B:S19, 2005; Ryan S: Chronic obstructive pulmonary disease: boosting quality of
life. Community Nurse 6:31, 2000; Trappenburg JC et al: Psychosocial conditions do not affect short-term outcome
of multidisciplinary rehabilitation in chronic obstructive pulmonary disease. Arch Phys Med Rehabil 86:1788,
2005; Troosters T et al: Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care
Med 172:19, 2005.
Educational Objectives
| The goal of this program is to improve preparedness for pandemic influenza and to improve management of chronic
obstructive pulmonary disease (COPD). After hearing and assimilating this program, the clinician will be better able
to:
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 | 1. Describe subtypes of avian influenza A virus.
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| 2. Discuss what to expect in the event of an influenza pandemic.
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| 3. Coordinate with public officials and local community to prepare facilities for pandemic influenza.
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| 4. Counsel patients with COPD to improve muscle wasting and depression, in addition to lung function.
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| 5. Choose effective medications for COPD.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members
to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the following has been disclosed: Dr. Yawn has received research grants from Boehringer
Ingelheim, GlaxoSmithKline, and Pfizer Inc; Dr. Mackett and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Mackett and Yawn spoke in Chicago, IL, at the 50th annual Scientific Assembly, presented by the American Academy
of Family Physicians. The Audio-Digest Foundation thanks the speakers and the American Academy of Family Physicians
for their cooperation in the production of this program.
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