This or that… Asthma vs COPD

So how can you tell if your adult patient has asthma or COPD.  Sometimes you can’t, and sometimes it might be both.  But here are some clues.

helpful conceptualization from Medscape

Clinical course: The hallmark of asthma is intermittent episodes of obstruction or bronchospasm. These patients, particularly at onset, often have asymptomatic periods.  COPD, on the other hand, is slowly progressive and NOT reversible. Patients clearly have exacerbations, but are rarely completely symptom free.

Age at onset: Asthma patients tend to be younger. They may be able to identify specific triggers: allergens (pets), irritants (tobacco smoke), exercise, temperature. COPD is due to long-standing exposures, so patients are older, and almost always have a smoking history.

PFTs: Asthma and COPD both have an obstructive pattern on PFTs. Think low FEV1/FVC ratio, larger lung volumes. The difference is that the obstruction seen in asthmatics is REVERSIBLE with bronchodilators. The bronchodilator administration is necessary for the diagnosis of asthma. Specific criteria are that FEV1 increases more than 12% over baseline or Peak Flow increases > 20% over baseline with bronchodilator. Normal PFTs essentially rule out COPD, but PFTs can be normal in an asymptomatic asthmatic.

Wondering what else is in the differential?  Check out this post from 2013.

Pneumonia Shots- Part 2: Immunocompromised Adults

Welcome back to Part 2 of the great Prevnar vs Pneumovax Update here at I Hate Rashes.

Last time, I talked about the differences between the two vaccines and the current recommendations for adults >65.  To recap, Pneumovax is a polysaccharide vaccine that covers 23 serotypes of S. Pneumoniae (PPSV23).  This is great because it is so broad.  Prevnar is a Conjugate polysaccharide vaccine that covers 13 serotypes (PCV13).  This is great because conjugating the pneumococcal polysaccharide to a diphtheria toxin boosts immunity and helps lead to herd immunity.  ACIP currently recommends that we give both PCV13 and PPSV 23 to our patients over 65. It is probably best to give PCV 13 first if the patient hasn’t had any pneumococcal vaccines. 
But what about all of those adults who get the pneumococcal vaccine BEFORE age 65? What should we do with them?  It is probably helpful to divide our recommendations between the immunocompetent vs immunocompromised conditions.

Those who are immunocompromised actually have long been recommended to get both PCV13 and PPSV23. This includes patients with asplenia, CSF leaks,  cochlear implants, HIV and other immunodeficiencies, nephrotic syndrome, leukemia/lymphoma, myeloma, transplants, and iatrogenic immunosuppression.  Iatrogenic immunosuppression includes chronic steroids, radiation therapy, and probably immunomodulators used in rheumatologic diseases. Most of these will need revaccination with PPSV23 5 years after their first vaccine: there is no need to revaccinate with the PCV13.

The immunocompetent patients continue to get just the PPSV23 prior to age 65.  This is for our patients with diabetes, COPD/Asthma/smoking, chronic heart disease, and chronic liver disease/alcoholism.  Once they turn 65, give them PCV13 and then repeat the PPSV23 about a year later.

Here’s a handy chart if you are more of a visual learner.

Risk group

Underlying medical condition

PCV13

PPSV23

Recommended

Recommended

Revaccination 5 yrs after first dose

Immunocompetent persons

Chronic heart disease

Chronic lung disease§

Diabetes mellitus

Cerebrospinal fluid leak

Cochlear implant

Alcoholism

Chronic liver disease, cirrhosis

Cigarette smoking

Persons with functional or anatomic asplenia

Sickle cell disease/other hemoglobinopathy

Congenital or acquired asplenia

Immunocompromised persons

Congenital or acquired immunodeficiency

Human immunodeficiency virus infection

Chronic renal failure

Nephrotic syndrome

Leukemia

Lymphoma

Hodgkin disease

Generalized malignancy

Iatrogenic immunosuppression**

Solid organ transplant

Multiple myeloma

Let’s practice some more:  For each patient, do you give PCV13 vs PPSV2, or both

  1. 55 newly diagnosed diabetic
  2. 60 year old with COPD, never had pneumococcal vaccine before
  3. 62 year old with COPD, had PPSV23 3 years ago, takes prednisone 5mg daily.
  4. 25 year old with coclear implants, never had pneumococcal vaccine before
  5. 35 year old with well controlled HIV, never had PCV13, had PPSV23 10 years ago, at diagnosis.

Let me know your answers or questions in the comments!

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.

 

“Incidental” Pulmonary Hypertension

After the post about incidental findings a few weeks ago, I have been noticing them more and more.  Not sure if I am really chasing more things, or if I have availability bias. Either way, costs and patient anxiety are adding up. 

Anyway, this came up in clinic recently: a surprise finding of pulmonary hypertension. An excellent resident came to me with his plan, which was perfect, but I have found myself looking this up a time or two. Thought you all might appreciate a review, as I did.

Typically, pulmonary hypertension is found on an echocardiogram, as it was in this case. The most common symptoms are exertional dyspnea, lethargy, and fatigue; common reasons to get an echo.  This really isn’t incidental, but more commonly just “surprise, now what do i do?” clinical dilemma.

So what next? First, decide if the pulmonary hypertension seems consistent with the patient’s symptoms, and if their values are reasonable to warrant further workup. Initially, patient’s are unable to increase cardiac output to match demand with exertion. So they present with exertional dyspnea and fatigue.  With more advanced PH, they develop right heart hypertrophy and subsequent right heart failure symptoms (edema, abdominal pain from hepatic congestion). Angina is also often present, due to inability to perfuse the subendocardium of the thicker heart wall. Sometimes there is actually compression of the left coronary artery by a big pulmonary artery- leading to angina.

So that sounds like it could be your patient. Are you satisfied with pulmonary hypertension as an explanation?  Echocardiogram estimates pulmonary artery pressure by looking at the jet behind tricuspid regurgitation and the IVC to estimate right atrial pressure.  So if there is no TR, or only weak TR, the PA pressure estimation is less reliable.  Assuming good views,

  • PH likely if PA pressure estimation >50 and TR jet velocity >340 cm/s 
  • PH unlikely if PA Pressure <36 and TR jet velocity is <280 cm/s
  • In between those findings, it is more gray, and a combination of lower pressures plus higher jet velocity, or vice versa, could get you a diagnosis.

OK- let’s say our patient has echo findings that fit the “likely” scenario above (both are easy to find on UAB echo reports, FYI).  Next step is to decide if this is secondary PH or idiopathic PH. Ultimately, many of these patients will need a right heart catheterization if specific treatment for PH is indicated (which we are NOT going to be doing in the clinic).  However, there are some common secondary PH syndromes that we can find and treat. Some possible secondary diagnoses:

  • Left sided heart disease: Probably most common reason for PH. This should be clear from the echo you already got (and your history and physical).
  • Lung disease: PH can be due to either COPD or severe restrictive lung disease (lung volumes <50% predicted).  If PFTs are only mildly abnormal, lung disease is probably not to blame for the PH.
    • So order PFTs
  • Sleep Apnea: An increasingly common diagnosis and certainly worth diagnosing and treating.  First ask about potential OSA (snoring, non-restorative sleep, daytime somnolence, headaches), and then screen
    • Overnight PSG is the gold standard, although could consider overnight pulse oximetry at home if sleep study is hard to get and your suspicion is low.  Will likely need the sleep study to get the CPAP.
  • Chronic PTE:  Much less likely, but it is found every now and then.  My practice is to hold off on this evaluation at first unless the PH is severe or the patient has other reasons to make me suspect chronic clots.
    • Usually start with a VQ scan as it is much more sensitive for chronic PE than CTA.
  • Portopulmonary Hypertension: So maybe your patient’s cirrhosis is leading to portal hypertension, backing up to the right side of the heart.  Sort of the opposite of passive hepatic congestion.Hopefully you know if your patient is cirrhotic, but easy enough to investigate if you don’t.
    • LFTs, consider abdominal US.  Keep in mind though, that US is not really going to tell you the difference between hepatic congestion starting in the heart and congestion starting in the liver.
  • Connective Tissue Disease:  Most likely you will also see the interstitial lung disease on your PFTs if this is your diagnosis, but not always. You could wait and get your PFTs first.
    • Rheum labs, specifically ANA, RF, anti-CCP (if high suspicion), ANCA
  • HIV infection can cause PH. Lung biopsy shows plexiform lesions of endothelial cells, that looks the same as idiopathic PAH. Pathogenesis is not clear (at least to me).
    • HIV antibodies
  • Chronic Hemolytic Anemia: Again, you would usually know if your patient has a reason for this, like Sickle Cell Disease.  A big workup is not usually indicated for all patients with pulmonary hypertension.

If none of those fit, then idiopathic PH is more likely, and you should think about referral to pulmonary hypertension clinic. Hopefully that will get you on the right track.  By no means do you have to do all these things at once, but let your patient, their most likely etiologies, and the severity of their symptoms be your guide. Remember, the beauty of outpatient practice is that there is TIME to work these things up in a stepwise process (even if you never feel that you have time in clinic- you do!)

Thoughts, questions, did I get something totally wrong?  Please drop me a line in the comments sections and straighten me out.  Or just let me know that I’m not talking to myself out here!

Pulmonary Artery Angiogram Image above from Up To Date 12.0, which has a great review of this topic, and an algorithm for the workup.

Blue lips are from the pulmonary hypertension association.